Provider Demographics
NPI:1730279019
Name:LAVINE, MARTIN (MS, PT)
Entity Type:Individual
Prefix:MR
First Name:MARTIN
Middle Name:
Last Name:LAVINE
Suffix:
Gender:M
Credentials:MS, PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:38 E 5TH AVE
Mailing Address - Street 2:#180
Mailing Address - City:DENVER
Mailing Address - State:CO
Mailing Address - Zip Code:80203-3436
Mailing Address - Country:US
Mailing Address - Phone:303-893-0047
Mailing Address - Fax:720-570-7996
Practice Address - Street 1:38 E 5TH AVE
Practice Address - Street 2:#180
Practice Address - City:DENVER
Practice Address - State:CO
Practice Address - Zip Code:80203-3436
Practice Address - Country:US
Practice Address - Phone:303-893-0047
Practice Address - Fax:720-570-7996
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-15
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO4772225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO444428Medicare ID - Type Unspecified