Provider Demographics
NPI:1205086733
Name:DAGOSTINE, MICHELLE LAVALLEE (MD)
Entity type:Individual
Prefix:DR
First Name:MICHELLE
Middle Name:LAVALLEE
Last Name:DAGOSTINE
Suffix:
Gender:F
Credentials:MD
Other - Prefix:DR
Other - First Name:MICHELLE
Other - Middle Name:MARIE
Other - Last Name:LAVALLEE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:280 SOUTH MAIN STREET
Mailing Address - Street 2:SUITE 102
Mailing Address - City:CHESHIRE
Mailing Address - State:CT
Mailing Address - Zip Code:06410
Mailing Address - Country:US
Mailing Address - Phone:860-870-6385
Mailing Address - Fax:
Practice Address - Street 1:280 SOUTH MAIN STREET
Practice Address - Street 2:SUITE 102
Practice Address - City:CHESHIRE
Practice Address - State:CT
Practice Address - Zip Code:06410
Practice Address - Country:US
Practice Address - Phone:860-870-6385
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-09-20
Last Update Date:2022-06-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DCMD0374052084N0400X
CT487662084N0400X
VA01012460552084N0400X
CT0487662084N0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CTD400026892Medicare PIN