Provider Demographics
NPI:1114282274
Name:M LAVIAN MD LLC
Entity type:Organization
Organization Name:M LAVIAN MD LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:MANOUCHEHR
Authorized Official - Middle Name:
Authorized Official - Last Name:LAVIAN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:845-341-1805
Mailing Address - Street 1:129 WICKHAM AVE
Mailing Address - Street 2:
Mailing Address - City:MIDDLETOWN
Mailing Address - State:NY
Mailing Address - Zip Code:10940-3714
Mailing Address - Country:US
Mailing Address - Phone:845-341-1805
Mailing Address - Fax:845-342-9218
Practice Address - Street 1:129 WICKHAM AVE
Practice Address - Street 2:
Practice Address - City:MIDDLETOWN
Practice Address - State:NY
Practice Address - Zip Code:10940-3714
Practice Address - Country:US
Practice Address - Phone:845-341-1805
Practice Address - Fax:845-342-9218
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-07-05
Last Update Date:2012-11-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY163228-12084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY12F912Medicare UPIN