Provider Demographics
NPI:1154482594
Name:LAVINE, MARK A (OD)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:A
Last Name:LAVINE
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5448 VAN NESS DR
Mailing Address - Street 2:
Mailing Address - City:BLOOMFIELD HILLS
Mailing Address - State:MI
Mailing Address - Zip Code:48302-2670
Mailing Address - Country:US
Mailing Address - Phone:248-857-2353
Mailing Address - Fax:
Practice Address - Street 1:354 W 14 MILE RD
Practice Address - Street 2:OAKLAND MALL
Practice Address - City:TROY
Practice Address - State:MI
Practice Address - Zip Code:48083-4218
Practice Address - Country:US
Practice Address - Phone:248-585-0044
Practice Address - Fax:248-585-5525
Is Sole Proprietor?:No
Enumeration Date:2006-12-12
Last Update Date:2010-05-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4901002664152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MIN34040068Medicare PIN
MIU31648Medicare UPIN