Provider Demographics
NPI:1770647943
Name:LAVIN, KENNETH MICHAEL (DPM)
Entity Type:Individual
Prefix:
First Name:KENNETH
Middle Name:MICHAEL
Last Name:LAVIN
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:272 CHAUNCY STREET
Mailing Address - Street 2:
Mailing Address - City:MANSFIELD
Mailing Address - State:MA
Mailing Address - Zip Code:02048
Mailing Address - Country:US
Mailing Address - Phone:508-339-3338
Mailing Address - Fax:508-339-4758
Practice Address - Street 1:272 CHAUNCY STREET SUITE 4
Practice Address - Street 2:
Practice Address - City:MANSFIELD
Practice Address - State:MA
Practice Address - Zip Code:02048
Practice Address - Country:US
Practice Address - Phone:508-339-3338
Practice Address - Fax:508-339-4758
Is Sole Proprietor?:No
Enumeration Date:2006-12-21
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MAMA1918213EP1101X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213EP1101XPodiatric Medicine & Surgery Service ProvidersPodiatristPrimary Podiatric Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
V10402Medicare UPIN
Y70959Medicare ID - Type Unspecified