Provider Demographics
NPI:1447486741
Name:LAVALLEE, MICHAEL A JR (DO)
Entity type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:A
Last Name:LAVALLEE
Suffix:JR
Gender:M
Credentials:DO
Other - Prefix:
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Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:4 SHAWS CV
Mailing Address - Street 2:SUITE 204
Mailing Address - City:NEW LONDON
Mailing Address - State:CT
Mailing Address - Zip Code:06320-4956
Mailing Address - Country:US
Mailing Address - Phone:860-447-2377
Mailing Address - Fax:
Practice Address - Street 1:4 SHAWS CV
Practice Address - Street 2:SUITE 204
Practice Address - City:NEW LONDON
Practice Address - State:CT
Practice Address - Zip Code:06320-4956
Practice Address - Country:US
Practice Address - Phone:860-447-2377
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-06-02
Last Update Date:2013-05-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
CT051963207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT051963OtherLICENSE