Provider Demographics
NPI:1760465942
Name:GUGINO, LAVERNE D (MD)
Entity Type:Individual
Prefix:
First Name:LAVERNE
Middle Name:D
Last Name:GUGINO
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 1:3 MARYLAND FARMS STE 200
Mailing Address - Street 2:
Mailing Address - City:BRENTWOOD
Mailing Address - State:TN
Mailing Address - Zip Code:37027-5005
Mailing Address - Country:US
Mailing Address - Phone:615-345-5400
Mailing Address - Fax:888-468-6603
Practice Address - Street 1:119 SUMMIT AVE
Practice Address - Street 2:
Practice Address - City:WINTHROP
Practice Address - State:MA
Practice Address - Zip Code:02152
Practice Address - Country:US
Practice Address - Phone:617-418-0478
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-11-22
Last Update Date:2018-12-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA46992207L00000X, 2084N0600X
MA239565207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
Yes2084N0600XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyClinical Neurophysiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA6166253Medicaid
MA6165362Medicaid
MAJ01021OtherBLUE CROSS BLUE SHIELD
RILG58278Medicaid
MAA56136Medicare UPIN
MAHX4585Medicare PIN
RILG58278Medicaid
MA6165362Medicaid