Healthcare Provider Details

I. General information

NPI: 1407816408
Provider Name (Legal Business Name): DAVID M. LAVINE M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/24/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

800 8TH AVE SUITE 200
FORT WORTH TX
76104-2619
US

IV. Provider business mailing address

800 8TH AVE SUITE 200
FORT WORTH TX
76104-2619
US

V. Phone/Fax

Practice location:
  • Phone: 817-335-6457
  • Fax: 817-334-0491
Mailing address:
  • Phone: 817-335-6457
  • Fax: 817-334-0491

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2086S0122X
TaxonomyPlastic and Reconstructive Surgery Physician
License NumberE0082
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: