Provider Demographics
NPI:1982736427
Name:LAVIGNE, MARK K (MD)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:K
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 1:1705 BERWICK DR # B
Mailing Address - Street 2:
Mailing Address - City:LAURINBURG
Mailing Address - State:NC
Mailing Address - Zip Code:28352-5523
Mailing Address - Country:US
Mailing Address - Phone:910-610-4368
Mailing Address - Fax:910-610-4388
Practice Address - Street 1:1705 BERWICK DR # B
Practice Address - Street 2:
Practice Address - City:LAURINBURG
Practice Address - State:NC
Practice Address - Zip Code:28352-5523
Practice Address - Country:US
Practice Address - Phone:910-610-4368
Practice Address - Fax:910-610-4388
Is Sole Proprietor?:No
Enumeration Date:2007-03-11
Last Update Date:2008-01-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC9400093207Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Y00000XAllopathic & Osteopathic PhysiciansOtolaryngology
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCN00093Medicaid
NC8951170Medicaid
NC040008249OtherRAILROAD MEDICARE
NCG03673Medicare UPIN
NC040008249OtherRAILROAD MEDICARE