Basic Information
| Provider Information | |||||||||
| NPI: | 1417990383 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | LAVERY | ||||||||
| FirstName: | SARAH | ||||||||
| MiddleName: | GILBERT | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | GILBERT | ||||||||
| OtherFirstName: | SARAH | ||||||||
| OtherMiddleName: | DUNCANSON | ||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | M.D. | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 3660 ARLINGTON AVE | ||||||||
| Address2: | |||||||||
| City: | RIVERSIDE | ||||||||
| State: | CA | ||||||||
| PostalCode: | 925063912 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9516836370 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 7117 BROCKTON AVE | ||||||||
| Address2: | |||||||||
| City: | RIVERSIDE | ||||||||
| State: | CA | ||||||||
| PostalCode: | 925062615 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9513216335 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/14/2006 | ||||||||
| LastUpdateDate: | 09/14/2011 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | 39633 | KY | N | Allopathic & Osteopathic Physicians | Internal Medicine | 207R00000X | 061616 | GA | N | Allopathic & Osteopathic Physicians | Internal Medicine | 207R00000X | C54840 | CA | Y | Allopathic & Osteopathic Physicians | Internal Medicine |
ID Information
| ID | Type | State | Issuer | Description | 2599755 | 05 | OH | MEDICAID | P00264745 | 01 | KY | RAILROAD MEDICARE | OTHER | 64104169 | 05 | KY | MEDICAID |