Provider Demographics
NPI:1619996451
Name:LAVIS, TIMOTHY D (MD)
Entity Type:Individual
Prefix:DR
First Name:TIMOTHY
Middle Name:D
Last Name:LAVIS
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1201 BROAD ROCK BLVD
Mailing Address - Street 2:
Mailing Address - City:RICHMOND
Mailing Address - State:VA
Mailing Address - Zip Code:23249-0001
Mailing Address - Country:US
Mailing Address - Phone:804-675-5455
Mailing Address - Fax:804-675-5223
Practice Address - Street 1:1201 BROAD ROCK BLVD
Practice Address - Street 2:
Practice Address - City:RICHMOND
Practice Address - State:VA
Practice Address - Zip Code:23249-0001
Practice Address - Country:US
Practice Address - Phone:804-675-5455
Practice Address - Fax:804-675-5223
Is Sole Proprietor?:No
Enumeration Date:2006-07-19
Last Update Date:2013-04-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC2006-00544208100000X, 2081P0004X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2081P0004XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationSpinal Cord Injury Medicine
No208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & Rehabilitation
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC14228OtherNCBCBS
NC5903885Medicaid
SCN0054AMedicaid
NC2055662AMedicare PIN
NCI61016Medicare UPIN
NC5903885Medicaid
SCN0054AMedicaid