Provider Demographics
NPI:1013900919
Name:LAVA, NEIL S (MD)
Entity Type:Individual
Prefix:DR
First Name:NEIL
Middle Name:S
Last Name:LAVA
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 1:12 EXECUTIVE PARK DRIVE
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30329-2206
Mailing Address - Country:US
Mailing Address - Phone:404-778-3444
Mailing Address - Fax:404-712-7464
Practice Address - Street 1:12 EXECUTIVE PARK DRIVE
Practice Address - Street 2:
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30329-2206
Practice Address - Country:US
Practice Address - Phone:404-778-3444
Practice Address - Fax:404-712-7464
Is Sole Proprietor?:No
Enumeration Date:2005-08-25
Last Update Date:2015-10-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY121255-12084N0400X
GA601152084N0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurology
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA169085553HMedicaid
GA169085553HMedicaid
GA511I130013Medicare PIN