MEDICARE: LAVIZAN BALDEV

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	163WP0200X	Pediatric Registered Nurse	536970-1	NY

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1346408143
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	LAVIZAN BALDEV

Provider Business Mailing Address
First Line	:	8 ESTHER CT
Second Line	:
City	:	PATCHOGUE
State	:	NY
Zip	:	11772-1814
Country	:	US
Telephone Number	:	631-289-5797
Fax Number	:

Provider Business Practice Location Address
First Line	:	9 NORTON AVE
Second Line	:
City	:	PORT JEFFERSON STATION
State	:	NY
Zip	:	11776-4407
Country	:	US
Telephone Number	:	631-474-7878
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	05/28/2008
Last Update Date	:	05/28/2008

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