Provider Demographics
NPI:1992784094
Name:PACOLD, IVAN (MD)
Entity type:Individual
Prefix:
First Name:IVAN
Middle Name:
Last Name:PACOLD
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2160 S 1ST AVE
Mailing Address - Street 2:(1950 S. HARLEM AVE., NORTH RIVERSIDE, IL. 60546)
Mailing Address - City:MAYWOOD
Mailing Address - State:IL
Mailing Address - Zip Code:60153
Mailing Address - Country:US
Mailing Address - Phone:708-354-9250
Mailing Address - Fax:708-354-8765
Practice Address - Street 1:2160 S 1ST AVE
Practice Address - Street 2:(1950 S. HARLEM AVE., NORTH RIVERSIDE, IL. 60546)
Practice Address - City:MAYWOOD
Practice Address - State:IL
Practice Address - Zip Code:60153
Practice Address - Country:US
Practice Address - Phone:708-354-9250
Practice Address - Fax:708-354-8765
Is Sole Proprietor?:No
Enumeration Date:2006-01-17
Last Update Date:2010-03-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL36059612207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL36059612Medicaid
IL36059612Medicaid
ILK03792Medicare ID - Type Unspecified
E41103Medicare UPIN