Provider Demographics
NPI:1275693343
Name:LAVINE, LAWRENCE (DO)
Entity Type:Individual
Prefix:DR
First Name:LAWRENCE
Middle Name:
Last Name:LAVINE
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9424 VETERANS DRIVE SW
Mailing Address - Street 2:
Mailing Address - City:LAKEWOOD
Mailing Address - State:WA
Mailing Address - Zip Code:98498-1163
Mailing Address - Country:US
Mailing Address - Phone:253-589-4625
Mailing Address - Fax:253-581-6329
Practice Address - Street 1:9424 VETERANS DRIVE SW
Practice Address - Street 2:
Practice Address - City:LAKEWOOD
Practice Address - State:WA
Practice Address - Zip Code:98498-1163
Practice Address - Country:US
Practice Address - Phone:253-589-4625
Practice Address - Fax:253-581-6329
Is Sole Proprietor?:No
Enumeration Date:2006-12-11
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAOP00001467204D00000X, 2084N0402X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered204D00000XAllopathic & Osteopathic PhysiciansNeuromusculoskeletal Medicine & OMM
Not Answered2084N0402XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurology with Special Qualifications in Child Neurology
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA11110197Medicaid
D32411Medicare UPIN
WA11110197Medicaid