Provider Demographics
NPI:1043445398
Name:LAVOTSHKIN, SIMON (MD)
Entity type:Individual
Prefix:DR
First Name:SIMON
Middle Name:
Last Name:LAVOTSHKIN
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 1:2400 S AVENUE A
Mailing Address - Street 2:
Mailing Address - City:YUMA
Mailing Address - State:AZ
Mailing Address - Zip Code:85364-7170
Mailing Address - Country:US
Mailing Address - Phone:928-344-2000
Mailing Address - Fax:
Practice Address - Street 1:2270 S RIDGEVIEW DR STE 128
Practice Address - Street 2:
Practice Address - City:YUMA
Practice Address - State:AZ
Practice Address - Zip Code:85364-8875
Practice Address - Country:US
Practice Address - Phone:928-344-5055
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-05-15
Last Update Date:2025-01-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA125514208600000X
AZ63440208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAW20502OtherGROUP NUMBER