MEDICARE: DR. DAVID M. LAVINE M.D.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	2086S0122X	Plastic and Reconstructive Surgery Physician	E0082	TX

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	4019441	OTHER	TX	AETNA
2	00N791	OTHER	TX	BLUE CROSS BLUE SHIELD

General Provider Information

NPI Number	:	1407816408
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. DAVID M. LAVINE M.D.

Provider Business Mailing Address
First Line	:	800 8TH AVE
Second Line	:	SUITE 200
City	:	FORT WORTH
State	:	TX
Zip	:	76104-2619
Country	:	US
Telephone Number	:	817-335-6457
Fax Number	:	817-334-0491

Provider Business Practice Location Address
First Line	:	800 8TH AVE
Second Line	:	SUITE 200
City	:	FORT WORTH
State	:	TX
Zip	:	76104-2619
Country	:	US
Telephone Number	:	817-335-6457
Fax Number	:	817-334-0491

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	03/24/2006
Last Update Date	:	07/08/2007

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