Healthcare Provider Details

I. General information

NPI: 1407997992
Provider Name (Legal Business Name): MIKE E. PELIVANIS LDO
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/09/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4200 WISCONSIN AVE NW
WASHINGTON DC
20016-2143
US

IV. Provider business mailing address

4200 WISCONSIN AVE NW
WASHINGTON DC
20016-2143
US

V. Phone/Fax

Practice location:
  • Phone: 202-244-1308
  • Fax: 202-244-2050
Mailing address:
  • Phone: 202-244-1308
  • Fax: 202-244-2050

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code156FX1800X
TaxonomyOptician
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: