Provider Demographics
NPI:1225093362
Name:LAXER, MARIVYL J (MD)
Entity Type:Individual
Prefix:DR
First Name:MARIVYL
Middle Name:J
Last Name:LAXER
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
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Mailing Address - Street 1:200 MILL RD
Mailing Address - Street 2:STE 180
Mailing Address - City:FAIRHAVEN
Mailing Address - State:MA
Mailing Address - Zip Code:02719-5252
Mailing Address - Country:US
Mailing Address - Phone:508-973-2000
Mailing Address - Fax:508-973-2001
Practice Address - Street 1:827 AMERICAN LEGION HWY
Practice Address - Street 2:
Practice Address - City:WESTPORT
Practice Address - State:MA
Practice Address - Zip Code:02790-4128
Practice Address - Country:US
Practice Address - Phone:508-636-5101
Practice Address - Fax:508-636-3651
Is Sole Proprietor?:No
Enumeration Date:2006-04-20
Last Update Date:2020-04-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA153456207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA110059125AMedicaid
RIML25453Medicaid
RIML25453Medicaid
MAB10222403OtherCIGNA
RIML25453OtherMEDICAID
MAG49043Medicare UPIN
MA1001003OtherAETNA
MA153456OtherTUFTS HEALTH PLAN
MAA22671Medicare ID - Type UnspecifiedMEDICARE
MA3172830Medicaid
MA36847385OtherHEALTHSOURCE
MAJ17906OtherBLUE SHIELD
MA0403474OtherUNITED HEALTHCARE
RI401237OtherBLUE CHIP
MA690001OtherHARVARD PILGRIM
RI0000029260OtherBLUE SHIELD