Provider Demographics
NPI:1235118480
Name:LAVALLEY, ANTOINETTE LEE (MD)
Entity Type:Individual
Prefix:DR
First Name:ANTOINETTE
Middle Name:LEE
Last Name:LAVALLEY
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
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Other - Credentials:
Mailing Address - Street 1:3455 MILL RUN DRIVE
Mailing Address - Street 2:SUITE 450
Mailing Address - City:HILLIARD
Mailing Address - State:OH
Mailing Address - Zip Code:43026-9083
Mailing Address - Country:US
Mailing Address - Phone:614-771-2222
Mailing Address - Fax:614-771-2221
Practice Address - Street 1:2658 W. LASKEY ROAD
Practice Address - Street 2:2ND FLOOR
Practice Address - City:TOLEDO
Practice Address - State:OH
Practice Address - Zip Code:43613-3288
Practice Address - Country:US
Practice Address - Phone:419-473-8105
Practice Address - Fax:419-254-2121
Is Sole Proprietor?:No
Enumeration Date:2006-01-15
Last Update Date:2010-03-25
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
OH350524062085N0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085N0700XAllopathic & Osteopathic PhysiciansRadiologyNeuroradiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH711108Medicaid
OH35052406OtherLICENSE NUMBER
OH0711108Medicaid
OH35052406OtherLICENSE NUMBER
OH711108Medicaid
OH0711108Medicaid