Provider Demographics
NPI:1881635779
Name:LAVELLE, MICHAEL T JR (MD)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:T
Last Name:LAVELLE
Suffix:JR
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 6095
Mailing Address - Street 2:
Mailing Address - City:BEND
Mailing Address - State:OR
Mailing Address - Zip Code:97708-6095
Mailing Address - Country:US
Mailing Address - Phone:541-706-5922
Mailing Address - Fax:541-706-6869
Practice Address - Street 1:2200 NE NEFF RD
Practice Address - Street 2:
Practice Address - City:BEND
Practice Address - State:OR
Practice Address - Zip Code:97701-4283
Practice Address - Country:US
Practice Address - Phone:541-548-7761
Practice Address - Fax:541-526-6554
Is Sole Proprietor?:No
Enumeration Date:2006-06-09
Last Update Date:2024-01-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORMD25547208800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208800000XAllopathic & Osteopathic PhysiciansUrology
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR277995Medicaid
OR277995Medicaid
OR131440Medicare ID - Type Unspecified