Provider Demographics
NPI:1952484495
Name:LAVIGNA, RICHARD CHARLES (DPM)
Entity Type:Individual
Prefix:
First Name:RICHARD
Middle Name:CHARLES
Last Name:LAVIGNA
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 1:2844 SUMMIT ST STE 107
Mailing Address - Street 2:
Mailing Address - City:OAKLAND
Mailing Address - State:CA
Mailing Address - Zip Code:94609-3641
Mailing Address - Country:US
Mailing Address - Phone:510-463-3888
Mailing Address - Fax:510-433-0130
Practice Address - Street 1:2844 SUMMIT ST STE 107
Practice Address - Street 2:
Practice Address - City:OAKLAND
Practice Address - State:CA
Practice Address - Zip Code:94609-3641
Practice Address - Country:US
Practice Address - Phone:510-463-3888
Practice Address - Fax:510-433-0130
Is Sole Proprietor?:No
Enumeration Date:2006-10-20
Last Update Date:2015-09-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAE3779213ES0103X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA000E37792Medicaid
CA000E37792Medicare ID - Type UnspecifiedMEDICARE ID NO
CAU18843Medicare UPIN