Healthcare Provider Details

I. General information

NPI: 1992784094
Provider Name (Legal Business Name): IVAN PACOLD MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/17/2006
Last Update Date: 03/04/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2160 S 1ST AVE (1950 S. HARLEM AVE., NORTH RIVERSIDE, IL. 60546)
MAYWOOD IL
60153
US

IV. Provider business mailing address

2160 S 1ST AVE (1950 S. HARLEM AVE., NORTH RIVERSIDE, IL. 60546)
MAYWOOD IL
60153
US

V. Phone/Fax

Practice location:
  • Phone: 708-354-9250
  • Fax: 708-354-8765
Mailing address:
  • Phone: 708-354-9250
  • Fax: 708-354-8765

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RC0000X
TaxonomyCardiovascular Disease Physician
License Number36059612
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: