Provider Demographics
NPI:1821065160
Name:LAVIN, MARK (MD)
Entity Type:Individual
Prefix:DR
First Name:MARK
Middle Name:
Last Name:LAVIN
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 1:14003 BOND ST
Mailing Address - Street 2:
Mailing Address - City:OVERLAND PARK
Mailing Address - State:KS
Mailing Address - Zip Code:66221-2830
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:19609 E 9TH ST S
Practice Address - Street 2:
Practice Address - City:INDEPENDENCE
Practice Address - State:MO
Practice Address - Zip Code:64056-3088
Practice Address - Country:US
Practice Address - Phone:816-796-1412
Practice Address - Fax:816-796-3398
Is Sole Proprietor?:No
Enumeration Date:2006-03-07
Last Update Date:2008-03-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MOR3P612085R0202X, 2085B0100X
KS04-181352085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
No2085B0100XAllopathic & Osteopathic PhysiciansRadiologyBody Imaging
Provider Identifiers
StateIdentifier IDID TypeIssuer
KSP00152929OtherRR MEDICARE
MSP00152876OtherRR MEDICARE
KSP00152929Medicare PIN
MSP00152876OtherRR MEDICARE
MOA47513Medicare UPIN
MOP00152876Medicare PIN
MO0569445AMedicare PIN
MOK679445Medicare PIN
KSP00152929OtherRR MEDICARE