Provider Demographics
NPI:1972583953
Name:LAVELANET, MARIO (MD)
Entity Type:Individual
Prefix:DR
First Name:MARIO
Middle Name:
Last Name:LAVELANET
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 1:8039 159TH ST
Mailing Address - Street 2:
Mailing Address - City:JAMAICA
Mailing Address - State:NY
Mailing Address - Zip Code:11432-1103
Mailing Address - Country:US
Mailing Address - Phone:718-969-2367
Mailing Address - Fax:718-969-5084
Practice Address - Street 1:11751 220TH ST
Practice Address - Street 2:
Practice Address - City:CAMBRIA HEIGHTS
Practice Address - State:NY
Practice Address - Zip Code:11411-1608
Practice Address - Country:US
Practice Address - Phone:718-723-4303
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-01-18
Last Update Date:2014-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY190765207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01616568Medicaid
NYF51516Medicare UPIN
NY01616568Medicaid