Provider Demographics
NPI:1043445398
Name:LAVOTSHKIN, SIMON (MD)
Entity Type:Individual
Prefix:DR
First Name:SIMON
Middle Name:
Last Name:LAVOTSHKIN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
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Other - Credentials:
Mailing Address - Street 1:5565 GROSSMONT CENTER DRIVE
Mailing Address - Street 2:SUITE 221 BLD #1
Mailing Address - City:LA MESA
Mailing Address - State:CA
Mailing Address - Zip Code:91942
Mailing Address - Country:US
Mailing Address - Phone:619-462-8100
Mailing Address - Fax:619-462-7933
Practice Address - Street 1:5565 GROSSMONT CENTER DRIVE
Practice Address - Street 2:BLD #1 SUITE 221
Practice Address - City:LA MESA
Practice Address - State:CA
Practice Address - Zip Code:91942
Practice Address - Country:US
Practice Address - Phone:619-462-8100
Practice Address - Fax:619-462-7933
Is Sole Proprietor?:Yes
Enumeration Date:2009-05-15
Last Update Date:2016-02-17
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
CA125514208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAW20502OtherGROUP NUMBER