Provider Demographics
NPI:1003811233
Name:LAVAN, FREDERICK B (MD)
Entity Type:Individual
Prefix:DR
First Name:FREDERICK
Middle Name:B
Last Name:LAVAN
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 1:1007 MANTUA PIKE, SUITE B
Mailing Address - Street 2:
Mailing Address - City:WOODBURY
Mailing Address - State:NJ
Mailing Address - Zip Code:08096-3963
Mailing Address - Country:US
Mailing Address - Phone:856-256-7705
Mailing Address - Fax:856-256-7709
Practice Address - Street 1:1007 MANTUA PIKE, SUITE B
Practice Address - Street 2:
Practice Address - City:WOODBURY
Practice Address - State:NJ
Practice Address - Zip Code:08096-3963
Practice Address - Country:US
Practice Address - Phone:856-256-7705
Practice Address - Fax:856-256-7709
Is Sole Proprietor?:No
Enumeration Date:2005-06-15
Last Update Date:2018-08-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD041474E208200000X
NJ25MA06432800208200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208200000XAllopathic & Osteopathic PhysiciansPlastic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ7403305Medicaid
PAF83067Medicare UPIN
NJF83067Medicare UPIN
NJ042494SYMMedicare ID - Type Unspecified
PA077386STKMedicare PIN