Healthcare Provider Details

I. General information

NPI: 1992759005
Provider Name (Legal Business Name): BRADFORD C LAVIGNE M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/22/2006
Last Update Date: 11/16/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

45 WELLS ST SUITE 103
WESTERLY RI
02891-2927
US

IV. Provider business mailing address

45 WELLS ST SUITE 103
WESTERLY RI
02891-2927
US

V. Phone/Fax

Practice location:
  • Phone: 401-596-6330
  • Fax: 401-348-0420
Mailing address:
  • Phone: 401-596-6330
  • Fax: 401-348-0420

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RG0100X
TaxonomyGastroenterology Physician
License NumberMD06550
License Number StateRI
# 2
Primary TaxonomyN
Taxonomy Code207RG0100X
TaxonomyGastroenterology Physician
License Number026027
License Number StateCT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: