Healthcare Provider Details

I. General information

NPI: 1821065160
Provider Name (Legal Business Name): MARK LAVIN MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/07/2006
Last Update Date: 03/13/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

19609 E 9TH ST S
INDEPENDENCE MO
64056-3088
US

IV. Provider business mailing address

14003 BOND ST
OVERLAND PARK KS
66221-2830
US

V. Phone/Fax

Practice location:
  • Phone: 816-796-1412
  • Fax: 816-796-3398
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License NumberR3P61
License Number StateMO
# 2
Primary TaxonomyN
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License Number04-18135
License Number StateKS
# 3
Primary TaxonomyN
Taxonomy Code2085B0100X
TaxonomyBody Imaging Physician
License NumberR3P61
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: