Provider Demographics
NPI:1992759005
Name:LAVIGNE, BRADFORD C (MD)
Entity type:Individual
Prefix:
First Name:BRADFORD
Middle Name:C
Last Name:LAVIGNE
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 1:45 WELLS ST
Mailing Address - Street 2:SUITE 103
Mailing Address - City:WESTERLY
Mailing Address - State:RI
Mailing Address - Zip Code:02891-2927
Mailing Address - Country:US
Mailing Address - Phone:401-596-6330
Mailing Address - Fax:401-348-0420
Practice Address - Street 1:45 WELLS ST
Practice Address - Street 2:SUITE 103
Practice Address - City:WESTERLY
Practice Address - State:RI
Practice Address - Zip Code:02891-2927
Practice Address - Country:US
Practice Address - Phone:401-596-6330
Practice Address - Fax:401-348-0420
Is Sole Proprietor?:No
Enumeration Date:2006-05-22
Last Update Date:2012-11-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
RIMD06550207RG0100X
CT026027207RG0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT003050119Medicaid
RIBL24810Medicaid
RI007009104Medicare ID - Type Unspecified
RIBL24810Medicaid
CT003050119Medicaid