Provider Demographics
NPI:1992937379
Name:LAVRENOV, ALEKSANDER VALENTINOVICH (DPM)
Entity type:Individual
Prefix:
First Name:ALEKSANDER
Middle Name:VALENTINOVICH
Last Name:LAVRENOV
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:20548 VENTURA BLVD
Mailing Address - Street 2:SUITE 217
Mailing Address - City:WOODLAND HILLS
Mailing Address - State:CA
Mailing Address - Zip Code:91364-6225
Mailing Address - Country:US
Mailing Address - Phone:917-687-7528
Mailing Address - Fax:
Practice Address - Street 1:20548 VENTURA BLVD
Practice Address - Street 2:SUITE 217
Practice Address - City:WOODLAND HILLS
Practice Address - State:CA
Practice Address - Zip Code:91364-6225
Practice Address - Country:US
Practice Address - Phone:917-687-7528
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-08-18
Last Update Date:2017-02-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY006226213ES0103X
CAE 5019213ES0103X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY6330200001Medicare NSC