Provider Demographics
NPI:1710427463
Name:LAVALLE, MARIA (OD)
Entity Type:Individual
Prefix:
First Name:MARIA
Middle Name:
Last Name:LAVALLE
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 1:285 WOLF DEN RD
Mailing Address - Street 2:
Mailing Address - City:ROYSTON
Mailing Address - State:GA
Mailing Address - Zip Code:30662-8230
Mailing Address - Country:US
Mailing Address - Phone:706-436-9479
Mailing Address - Fax:
Practice Address - Street 1:4804 CHAMBERS RD
Practice Address - Street 2:
Practice Address - City:DENVER
Practice Address - State:CO
Practice Address - Zip Code:80239-5152
Practice Address - Country:US
Practice Address - Phone:303-576-6655
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-02-28
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
COOPT.000331152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program