Provider Demographics
NPI:1306085212
Name:LAVIN, GORDON KYLE (MD)
Entity type:Individual
Prefix:
First Name:GORDON
Middle Name:KYLE
Last Name:LAVIN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:820 S BOYLAN AVE
Mailing Address - Street 2:2 EAST
Mailing Address - City:RALEIGH
Mailing Address - State:NC
Mailing Address - Zip Code:27603-2246
Mailing Address - Country:US
Mailing Address - Phone:919-733-5540
Mailing Address - Fax:919-733-9020
Practice Address - Street 1:820 S BOYLAN AVE
Practice Address - Street 2:2 EAST
Practice Address - City:RALEIGH
Practice Address - State:NC
Practice Address - Zip Code:27603-2246
Practice Address - Country:US
Practice Address - Phone:919-733-5540
Practice Address - Fax:919-733-9020
Is Sole Proprietor?:Yes
Enumeration Date:2009-02-17
Last Update Date:2009-02-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC249252084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC8951186Medicaid
NC8951186Medicaid