Provider Demographics
NPI:1285621474
Name:LAVERONI, EUGENE WALTER JR (DO)
Entity type:Individual
Prefix:
First Name:EUGENE
Middle Name:WALTER
Last Name:LAVERONI
Suffix:JR
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:26901 BEAUMONT BLVD STE 3D
Mailing Address - Street 2:
Mailing Address - City:SOUTHFIELD
Mailing Address - State:MI
Mailing Address - Zip Code:48033-3849
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:28100 GRAND RIVER AVE STE 200
Practice Address - Street 2:
Practice Address - City:FARMINGTON HILLS
Practice Address - State:MI
Practice Address - Zip Code:48336-5969
Practice Address - Country:US
Practice Address - Phone:947-521-8829
Practice Address - Fax:248-471-8352
Is Sole Proprietor?:No
Enumeration Date:2005-10-03
Last Update Date:2020-11-17
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MI51010092022086S0129X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2086S0129XAllopathic & Osteopathic PhysiciansSurgeryVascular Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI500564OtherDMC
MI3020482Medicaid
MIP69099OtherBCN
MI3020482Medicaid
F07129Medicare UPIN