Provider Demographics
NPI:1003828740
Name:LAVALLIE, BRAD J (OD)
Entity Type:Individual
Prefix:
First Name:BRAD
Middle Name:J
Last Name:LAVALLIE
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1035 KEPLER DR
Mailing Address - Street 2:
Mailing Address - City:GREEN BAY
Mailing Address - State:WI
Mailing Address - Zip Code:54311-8320
Mailing Address - Country:US
Mailing Address - Phone:920-490-9046
Mailing Address - Fax:
Practice Address - Street 1:2253 W MASON ST
Practice Address - Street 2:
Practice Address - City:GREEN BAY
Practice Address - State:WI
Practice Address - Zip Code:54303-4706
Practice Address - Country:US
Practice Address - Phone:920-327-7000
Practice Address - Fax:920-327-7005
Is Sole Proprietor?:No
Enumeration Date:2006-08-12
Last Update Date:2024-04-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI2706152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI38627900Medicaid
WI023507650Medicare ID - Type Unspecified
WI38627900Medicaid