Provider Demographics
NPI:1013922491
Name:LAVIAN, MANOUCHEHR (MD LLC)
Entity Type:Individual
Prefix:DR
First Name:MANOUCHEHR
Middle Name:
Last Name:LAVIAN
Suffix:
Gender:M
Credentials:MD LLC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:129 WICKHAM AVE
Mailing Address - Street 2:
Mailing Address - City:MIDDLETOWN
Mailing Address - State:NY
Mailing Address - Zip Code:10940-3714
Mailing Address - Country:US
Mailing Address - Phone:845-341-1805
Mailing Address - Fax:845-342-9218
Practice Address - Street 1:129 WICKHAM AVE
Practice Address - Street 2:
Practice Address - City:MIDDLETOWN
Practice Address - State:NY
Practice Address - Zip Code:10940-3714
Practice Address - Country:US
Practice Address - Phone:845-341-1805
Practice Address - Fax:845-342-9218
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-31
Last Update Date:2023-11-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY1632282084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY998527Medicaid
NY998527Medicaid
NY12F912Medicare PIN