Provider Demographics
NPI:1649238635
Name:LAVENBURG, DOUGLAS (MD)
Entity Type:Individual
Prefix:
First Name:DOUGLAS
Middle Name:
Last Name:LAVENBURG
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 1:103 CHESAPEAKE BLVD
Mailing Address - Street 2:STE C
Mailing Address - City:ELKTON
Mailing Address - State:MD
Mailing Address - Zip Code:21921
Mailing Address - Country:US
Mailing Address - Phone:410-392-6133
Mailing Address - Fax:410-392-4958
Practice Address - Street 1:103 CHESAPEAKE BLVD
Practice Address - Street 2:STE C
Practice Address - City:ELKTON
Practice Address - State:MD
Practice Address - Zip Code:21921
Practice Address - Country:US
Practice Address - Phone:410-392-6133
Practice Address - Fax:410-392-4958
Is Sole Proprietor?:No
Enumeration Date:2006-05-02
Last Update Date:2012-04-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DEC10002822207W00000X
MDD0036586207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
Provider Identifiers
StateIdentifier IDID TypeIssuer
DE0000542402Medicaid
MD116251900Medicaid
DE0000542402Medicaid
DE006853C37Medicare PIN
MD116251900Medicaid
E36063Medicare UPIN