Provider Demographics
NPI:1457300261
Name:AVALLONE, GARY JAMES (OD)
Entity Type:Individual
Prefix:DR
First Name:GARY
Middle Name:JAMES
Last Name:AVALLONE
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 1:144 FOX RUN
Mailing Address - Street 2:
Mailing Address - City:WEST MONROE
Mailing Address - State:LA
Mailing Address - Zip Code:71291-8137
Mailing Address - Country:US
Mailing Address - Phone:318-397-2041
Mailing Address - Fax:318-396-8936
Practice Address - Street 1:911 TECH DRIVE
Practice Address - Street 2:
Practice Address - City:RUSTON
Practice Address - State:LA
Practice Address - Zip Code:71270-0701
Practice Address - Country:US
Practice Address - Phone:318-251-9095
Practice Address - Fax:318-251-1705
Is Sole Proprietor?:No
Enumeration Date:2006-05-09
Last Update Date:2008-09-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA927-032T152W00000X
TX3151T152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1346870Medicaid
LA497197362Medicare PIN
LA1346870Medicaid