Healthcare Provider Details

I. General information

NPI: 1093861171
Provider Name (Legal Business Name): ANTHONY JAMES PAVEGLIO OD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/25/2007
Last Update Date: 07/17/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

52799 HAYS RD
SHELBY TOWNSHIP MI
48315
US

IV. Provider business mailing address

140 MACOMB
MT CLEMENS MI
48043
US

V. Phone/Fax

Practice location:
  • Phone: 586-247-2652
  • Fax:
Mailing address:
  • Phone: 586-468-7370
  • Fax: 586-464-1472

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number4901003257
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: