Provider Demographics
NPI:1801327309
Name:LAVIAN, JONATHAN (MD)
Entity type:Individual
Prefix:
First Name:JONATHAN
Middle Name:
Last Name:LAVIAN
Suffix:
Gender:
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:13835 N TATUM BLVD STE 9-268
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85032-5590
Mailing Address - Country:US
Mailing Address - Phone:480-418-3314
Mailing Address - Fax:480-923-6586
Practice Address - Street 1:2127 E BASELINE RD STE 104
Practice Address - Street 2:
Practice Address - City:TEMPE
Practice Address - State:AZ
Practice Address - Zip Code:85283-1537
Practice Address - Country:US
Practice Address - Phone:804-556-0446
Practice Address - Fax:480-556-0447
Is Sole Proprietor?:Yes
Enumeration Date:2017-03-26
Last Update Date:2025-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ66845207ND0101X, 207N00000X, 207N00000X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatology
No207ND0101XAllopathic & Osteopathic PhysiciansDermatologyMOHS-Micrographic Surgery
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program