Provider Demographics
NPI:1831276385
Name:DOUGLAS J LAVENBURG MD PA
Entity type:Organization
Organization Name:DOUGLAS J LAVENBURG MD PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:DOUGLAS
Authorized Official - Middle Name:J
Authorized Official - Last Name:LAVENBURG
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:410-392-6133
Mailing Address - Street 1:103 CHESAPEAKE BLVD STE C
Mailing Address - Street 2:
Mailing Address - City:ELKTON
Mailing Address - State:MD
Mailing Address - Zip Code:21921-6313
Mailing Address - Country:US
Mailing Address - Phone:410-392-6133
Mailing Address - Fax:410-392-4958
Practice Address - Street 1:103 CHESAPEAKE BLVD STE C
Practice Address - Street 2:
Practice Address - City:ELKTON
Practice Address - State:MD
Practice Address - Zip Code:21921-6313
Practice Address - Country:US
Practice Address - Phone:410-392-6133
Practice Address - Fax:410-392-4958
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-01
Last Update Date:2025-02-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DEC10002822152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
DE0000542402Medicaid
MD116251900Medicaid
MD116251900Medicaid
E36063Medicare UPIN
DEG01069Medicare ID - Type Unspecified