Provider Demographics
NPI:1396729711
Name:LAVALAIS, GWENDOLYN L (MD)
Entity type:Individual
Prefix:DR
First Name:GWENDOLYN
Middle Name:L
Last Name:LAVALAIS
Suffix:
Gender:F
Credentials:MD
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Mailing Address - Street 1:2450 N MAJOR DR
Mailing Address - Street 2:
Mailing Address - City:BEAUMONT
Mailing Address - State:TX
Mailing Address - Zip Code:77713-9575
Mailing Address - Country:US
Mailing Address - Phone:409-981-1800
Mailing Address - Fax:409-981-1890
Practice Address - Street 1:2450 N MAJOR DR
Practice Address - Street 2:
Practice Address - City:BEAUMONT
Practice Address - State:TX
Practice Address - Zip Code:77713-9575
Practice Address - Country:US
Practice Address - Phone:409-981-1800
Practice Address - Fax:409-981-1890
Is Sole Proprietor?:Yes
Enumeration Date:2005-11-30
Last Update Date:2022-08-25
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
TXM0468207RX0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RX0202XAllopathic & Osteopathic PhysiciansInternal MedicineMedical Oncology
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX176502601Medicaid
TX8F1342Medicare PIN
I43678Medicare UPIN