Healthcare Provider Details

I. General information

NPI: 1164786489
Provider Name (Legal Business Name): PAVIS LAENGVEJKAL MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/02/2012
Last Update Date: 07/02/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3601 4TH ST MS 9410
LUBBOCK TX
79430-0002
US

IV. Provider business mailing address

3601 4TH ST MS 9410
LUBBOCK TX
79430-0002
US

V. Phone/Fax

Practice location:
  • Phone: 806-743-3155
  • Fax: 806-743-2978
Mailing address:
  • Phone: 806-743-3155
  • Fax: 806-743-2978

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: