Healthcare Provider Details

I. General information

NPI: 1801327309
Provider Name (Legal Business Name): JONATHAN LAVIAN MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/26/2017
Last Update Date: 04/20/2025
Certification Date: 04/20/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2127 E BASELINE RD STE 104
TEMPE AZ
85283-1537
US

IV. Provider business mailing address

13835 N TATUM BLVD STE 9-268
PHOENIX AZ
85032-5590
US

V. Phone/Fax

Practice location:
  • Phone: 804-556-0446
  • Fax: 480-556-0447
Mailing address:
  • Phone: 480-418-3314
  • Fax: 480-923-6586

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207ND0101X
TaxonomyMOHS-Micrographic Surgery Physician
License Number66845
License Number StateAZ
# 2
Primary TaxonomyY
Taxonomy Code207N00000X
TaxonomyDermatology Physician
License Number66845
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: