Provider Demographics
NPI:1740239227
Name:LAVERY, JOHN PATRICK (MD)
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:PATRICK
Last Name:LAVERY
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:PO BOX 18025
Mailing Address - Street 2:
Mailing Address - City:BELFAST
Mailing Address - State:ME
Mailing Address - Zip Code:04915-4075
Mailing Address - Country:US
Mailing Address - Phone:972-747-0709
Mailing Address - Fax:972-747-7991
Practice Address - Street 1:1105 CENTRAL EXPY N
Practice Address - Street 2:230
Practice Address - City:ALLEN
Practice Address - State:TX
Practice Address - Zip Code:75013-6103
Practice Address - Country:US
Practice Address - Phone:972-747-0709
Practice Address - Fax:972-747-7991
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-10
Last Update Date:2019-10-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXH7453207RR0500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RR0500XAllopathic & Osteopathic PhysiciansInternal MedicineRheumatology
Provider Identifiers
StateIdentifier IDID TypeIssuer
TXA99618Medicare UPIN
TX00621GMedicare ID - Type Unspecified