Provider Demographics
NPI:1891734737
Name:LAVALLEE, MARILYN HUGUETTE (MD)
Entity Type:Individual
Prefix:
First Name:MARILYN
Middle Name:HUGUETTE
Last Name:LAVALLEE
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:513 E OGLETHORPE AVE STE F
Mailing Address - Street 2:
Mailing Address - City:SAVANNAH
Mailing Address - State:GA
Mailing Address - Zip Code:31401-4141
Mailing Address - Country:US
Mailing Address - Phone:912-999-8899
Mailing Address - Fax:912-480-0010
Practice Address - Street 1:513 E OGLETHORPE AVE STE F
Practice Address - Street 2:
Practice Address - City:SAVANNAH
Practice Address - State:GA
Practice Address - Zip Code:31401-4141
Practice Address - Country:US
Practice Address - Phone:912-999-8899
Practice Address - Fax:912-480-0010
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-06
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA053623207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA53263OtherSTATE LICENSE NUMBER
GA349793OtherWELLCARE
GA11SCDKBMedicare PIN
P00147365OtherRAILROAD MEDICARE
GA619198OtherWELLCARE
GA10065825OtherAMERIGROUP
GA598996582BMedicaid
I20270Medicare UPIN
GA598996582AMedicaid