Provider Demographics
NPI:1508421504
Name:FLAVIN, LILA MAE (MD)
Entity type:Individual
Prefix:
First Name:LILA
Middle Name:MAE
Last Name:FLAVIN
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:593 EDDY ST
Mailing Address - Street 2:
Mailing Address - City:PROVIDENCE
Mailing Address - State:RI
Mailing Address - Zip Code:02903-4923
Mailing Address - Country:US
Mailing Address - Phone:401-444-3830
Mailing Address - Fax:
Practice Address - Street 1:55 FRUIT ST
Practice Address - Street 2:
Practice Address - City:BOSTON
Practice Address - State:MA
Practice Address - Zip Code:02114-2621
Practice Address - Country:US
Practice Address - Phone:617-643-8281
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-05-06
Last Update Date:2024-08-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
RICMD192132084A0401X
NY3080792084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084A0401XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyAddiction Medicine
No2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
NAOtherNO OTHER IDENTIFIERS