Provider Demographics
NPI:1356600449
Name:LAVALLEY, REBECCA (MD)
Entity type:Individual
Prefix:
First Name:REBECCA
Middle Name:
Last Name:LAVALLEY
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 1:6 HAMPDEN PL
Mailing Address - Street 2:
Mailing Address - City:UTICA
Mailing Address - State:NY
Mailing Address - Zip Code:13502-5631
Mailing Address - Country:US
Mailing Address - Phone:315-733-2526
Mailing Address - Fax:315-733-2846
Practice Address - Street 1:6 HAMPDEN PL
Practice Address - Street 2:
Practice Address - City:UTICA
Practice Address - State:NY
Practice Address - Zip Code:13502-5631
Practice Address - Country:US
Practice Address - Phone:315-733-2526
Practice Address - Fax:315-733-2846
Is Sole Proprietor?:No
Enumeration Date:2012-05-09
Last Update Date:2016-03-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY281119207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY04270909Medicaid
NYJ400254457Medicare UPIN