Provider Demographics
NPI:1568446888
Name:GWENDOLYN L. LAVALAIS, M.D., P.A.
Entity Type:Organization
Organization Name:GWENDOLYN L. LAVALAIS, M.D., P.A.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:GWENDOLYN
Authorized Official - Middle Name:L
Authorized Official - Last Name:LAVALAIS
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:409-212-5930
Mailing Address - Street 1:3555 STAGG DRIVE
Mailing Address - Street 2:
Mailing Address - City:BEAUMONT
Mailing Address - State:TX
Mailing Address - Zip Code:77701
Mailing Address - Country:US
Mailing Address - Phone:409-212-5930
Mailing Address - Fax:409-212-5931
Practice Address - Street 1:3555 STAGG DRIVE
Practice Address - Street 2:
Practice Address - City:BEAUMONT
Practice Address - State:TX
Practice Address - Zip Code:77701
Practice Address - Country:US
Practice Address - Phone:409-212-5930
Practice Address - Fax:409-212-5931
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-11-30
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX207RX0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RX0202XAllopathic & Osteopathic PhysiciansInternal MedicineMedical OncologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX00626ZMedicare PIN