Provider Demographics
NPI:1538320395
Name:LAVERTY, CHAMINDRA G (MD)
Entity Type:Individual
Prefix:DR
First Name:CHAMINDRA
Middle Name:G
Last Name:LAVERTY
Suffix:
Gender:F
Credentials:MD
Other - Prefix:DR
Other - First Name:CHAMINDRA
Other - Middle Name:G
Other - Last Name:KONERSMAN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:PO BOX 232410
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92193-2410
Mailing Address - Country:US
Mailing Address - Phone:858-249-6749
Mailing Address - Fax:
Practice Address - Street 1:200 W ARBOR DR
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92103
Practice Address - Country:US
Practice Address - Phone:800-926-8273
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-06-24
Last Update Date:2023-01-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA1013512084N0008X, 2084N0400X
WI560812084N0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurology
No2084N0008XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeuromuscular Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI1538320395Medicaid