Healthcare Provider Details

I. General information

NPI: 1619020435
Provider Name (Legal Business Name): JOHN STEVE LAVENGOOD M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/18/2007
Last Update Date: 12/06/2021
Certification Date: 12/06/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1970 E 3RD AVE # UNTIL1
DURANGO CO
81301-5056
US

IV. Provider business mailing address

PO BOX 1328
DURANGO CO
81302-1328
US

V. Phone/Fax

Practice location:
  • Phone: 970-335-2288
  • Fax: 970-335-2280
Mailing address:
  • Phone: 970-335-2314
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number28293
License Number StateCO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: