Healthcare Provider Details

I. General information

NPI: 1225055015
Provider Name (Legal Business Name): CHARLES LAVIS M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/16/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1125 MARGUERITE ST
MORGAN CITY LA
70380-1855
US

IV. Provider business mailing address

PO BOX 2639
SAN ANTONIO TX
78299-2639
US

V. Phone/Fax

Practice location:
  • Phone: 985-384-2200
  • Fax:
Mailing address:
  • Phone: 337-824-4403
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License NumberMD01919R
License Number StateLA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: