Provider Demographics
NPI:1770575896
Name:LAVIGNE, RICHARD E (MD)
Entity type:Individual
Prefix:DR
First Name:RICHARD
Middle Name:E
Last Name:LAVIGNE
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 1:1444 WESTERN AVE
Mailing Address - Street 2:SUITE B-2
Mailing Address - City:ALBANY
Mailing Address - State:NY
Mailing Address - Zip Code:12203-3458
Mailing Address - Country:US
Mailing Address - Phone:518-458-8014
Mailing Address - Fax:518-533-6714
Practice Address - Street 1:1444 WESTERN AVE
Practice Address - Street 2:SUITE B-2
Practice Address - City:ALBANY
Practice Address - State:NY
Practice Address - Zip Code:12203-3458
Practice Address - Country:US
Practice Address - Phone:518-458-8014
Practice Address - Fax:518-533-6714
Is Sole Proprietor?:No
Enumeration Date:2005-08-16
Last Update Date:2021-05-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY101591207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY00370714Medicaid
NY00370714Medicaid
NYRA2857Medicare PIN