Provider Demographics
NPI:1629205513
Name:LAVINE, IRENA GLICK (MD)
Entity Type:Individual
Prefix:DR
First Name:IRENA
Middle Name:GLICK
Last Name:LAVINE
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10903 NEW HAMPSHIRE AVE
Mailing Address - Street 2:BUILDING 22, ROOM 5235
Mailing Address - City:SILVER SPRING
Mailing Address - State:MD
Mailing Address - Zip Code:20993-0002
Mailing Address - Country:US
Mailing Address - Phone:301-796-3862
Mailing Address - Fax:
Practice Address - Street 1:10903 NEW HAMPSHIRE AVE
Practice Address - Street 2:BUILDING 22, ROOM 5235
Practice Address - City:SILVER SPRING
Practice Address - State:MD
Practice Address - Zip Code:20993-0002
Practice Address - Country:US
Practice Address - Phone:301-796-3862
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-06-17
Last Update Date:2023-03-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101251997208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics