Provider Demographics
NPI:1275533960
Name:LAVELLE, MIRIAM J (OD)
Entity Type:Individual
Prefix:
First Name:MIRIAM
Middle Name:J
Last Name:LAVELLE
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:917 RIDGE RD
Mailing Address - Street 2:
Mailing Address - City:ROXBORO
Mailing Address - State:NC
Mailing Address - Zip Code:27573-4511
Mailing Address - Country:US
Mailing Address - Phone:336-599-0138
Mailing Address - Fax:336-599-0080
Practice Address - Street 1:917 RIDGE RD
Practice Address - Street 2:
Practice Address - City:ROXBORO
Practice Address - State:NC
Practice Address - Zip Code:27573-4511
Practice Address - Country:US
Practice Address - Phone:336-599-0138
Practice Address - Fax:336-599-0080
Is Sole Proprietor?:Yes
Enumeration Date:2005-07-26
Last Update Date:2013-01-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCNC1282152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC89-0919FMedicaid
NC0204COtherBCBS
NC2466686DMedicare PIN
NC0204COtherBCBS
NC89-0919FMedicaid