Provider Demographics
NPI:1669426003
Name:LAVENDER, TIMOTHY R (DO)
Entity type:Individual
Prefix:DR
First Name:TIMOTHY
Middle Name:R
Last Name:LAVENDER
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 1:108 N AUXIER AVE
Mailing Address - Street 2:
Mailing Address - City:PIKEVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:41501-9045
Mailing Address - Country:US
Mailing Address - Phone:606-432-9106
Mailing Address - Fax:606-432-0967
Practice Address - Street 1:108 N AUXIER AVE
Practice Address - Street 2:
Practice Address - City:PIKEVILLE
Practice Address - State:KY
Practice Address - Zip Code:41501-9045
Practice Address - Country:US
Practice Address - Phone:606-432-9106
Practice Address - Fax:606-432-0967
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-20
Last Update Date:2017-08-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY02627207NS0135X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207NS0135XAllopathic & Osteopathic PhysiciansDermatologyProcedural Dermatology
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY64005812Medicaid
KY9981Medicare PIN
KY64005812Medicaid