Provider Demographics
NPI:1649929860
Name:JOHN, LAVEENA MARIAM
Entity type:Individual
Prefix:
First Name:LAVEENA
Middle Name:MARIAM
Last Name:JOHN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4523 CLAYTON AVE
Mailing Address - Street 2:
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63110-1501
Mailing Address - Country:US
Mailing Address - Phone:314-454-8293
Mailing Address - Fax:314-454-5392
Practice Address - Street 1:4523 CLAYTON AVE
Practice Address - Street 2:
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63110-1501
Practice Address - Country:US
Practice Address - Phone:314-454-8293
Practice Address - Fax:313-343-8747
Is Sole Proprietor?:No
Enumeration Date:2022-03-23
Last Update Date:2025-06-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
MI4351049012207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program