Provider Demographics
NPI:1114092046
Name:LAVIGNA, RONALD M (DPM)
Entity Type:Individual
Prefix:DR
First Name:RONALD
Middle Name:M
Last Name:LAVIGNA
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1400 PROFESSIONAL DRIVE
Mailing Address - Street 2:SUITE 102
Mailing Address - City:PETALUMA
Mailing Address - State:CA
Mailing Address - Zip Code:94954
Mailing Address - Country:US
Mailing Address - Phone:707-769-8481
Mailing Address - Fax:707-769-0751
Practice Address - Street 1:1400 PROFESSIONAL DRIVE
Practice Address - Street 2:SUITE 102
Practice Address - City:PETALUMA
Practice Address - State:CA
Practice Address - Zip Code:94954
Practice Address - Country:US
Practice Address - Phone:707-769-8481
Practice Address - Fax:707-769-0751
Is Sole Proprietor?:No
Enumeration Date:2006-11-24
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAE1458213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAT10968Medicare UPIN