Provider Demographics
NPI:1407816408
Name:LAVINE, DAVID M (MD)
Entity Type:Individual
Prefix:DR
First Name:DAVID
Middle Name:M
Last Name:LAVINE
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:800 8TH AVE
Mailing Address - Street 2:SUITE 200
Mailing Address - City:FORT WORTH
Mailing Address - State:TX
Mailing Address - Zip Code:76104-2619
Mailing Address - Country:US
Mailing Address - Phone:817-335-6457
Mailing Address - Fax:817-334-0491
Practice Address - Street 1:800 8TH AVE
Practice Address - Street 2:SUITE 200
Practice Address - City:FORT WORTH
Practice Address - State:TX
Practice Address - Zip Code:76104-2619
Practice Address - Country:US
Practice Address - Phone:817-335-6457
Practice Address - Fax:817-334-0491
Is Sole Proprietor?:Yes
Enumeration Date:2006-03-24
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXE00822086S0122X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2086S0122XAllopathic & Osteopathic PhysiciansSurgeryPlastic and Reconstructive Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX4019441OtherAETNA
TX00N791OtherBLUE CROSS BLUE SHIELD
TX4019441OtherAETNA
TX00N791OtherBLUE CROSS BLUE SHIELD