1942282330 NPI number — DR. MARY LOIS LAVILLE MD

Table of content: DR. MARY LOIS LAVILLE MD (NPI 1942282330)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1942282330 NPI number — DR. MARY LOIS LAVILLE MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
LAVILLE
Provider First Name:
MARY
Provider Middle Name:
LOIS
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
MD
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1942282330
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/08/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
4630 AMBASSADOR CAFFERY PKWY
Provider Second Line Business Mailing Address:
SUITE 412
Provider Business Mailing Address City Name:
LAFAYETTE
Provider Business Mailing Address State Name:
LA
Provider Business Mailing Address Postal Code:
70508-6949
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
337-993-3933
Provider Business Mailing Address Fax Number:
337-993-2689

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
4630 AMBASSADOR CAFFERY PKWY
Provider Second Line Business Practice Location Address:
SUITE 412
Provider Business Practice Location Address City Name:
LAFAYETTE
Provider Business Practice Location Address State Name:
LA
Provider Business Practice Location Address Postal Code:
70508-6949
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
337-993-3933
Provider Business Practice Location Address Fax Number:
337-993-2689
Provider Enumeration Date:
11/19/2005

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 174400000X , with the licence number:  018789 , registered in the state of LA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 4375751 . This is a "AETNA" identifier , issued by the state of ( LA ) . This identifiers is of the category "OTHER".
  • Identifier: DC2141 . This is a "RAILROAD MEDICARE" identifier , issued by the state of ( LA ) . This identifiers is of the category "OTHER".
  • Identifier: 1399345 , issued by the state of ( LA ) . This identifiers is of the category "MEDICAID".




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