Healthcare Provider Details

I. General information

NPI: 1205086733
Provider Name (Legal Business Name): MICHELLE LAVALLEE DAGOSTINE M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: MICHELLE MARIE LAVALLEE M.D.

II. Dates (important events)

Enumeration Date: 09/20/2008
Last Update Date: 06/23/2022
Certification Date: 06/23/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

280 SOUTH MAIN STREET SUITE 102
CHESHIRE CT
06410
US

IV. Provider business mailing address

280 SOUTH MAIN STREET SUITE 102
CHESHIRE CT
06410
US

V. Phone/Fax

Practice location:
  • Phone: 860-870-6385
  • Fax:
Mailing address:
  • Phone: 860-870-6385
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2084N0400X
TaxonomyNeurology Physician
License NumberMD037405
License Number StateDC
# 2
Primary TaxonomyN
Taxonomy Code2084N0400X
TaxonomyNeurology Physician
License Number48766
License Number StateCT
# 3
Primary TaxonomyN
Taxonomy Code2084N0400X
TaxonomyNeurology Physician
License Number0101246055
License Number StateVA
# 4
Primary TaxonomyY
Taxonomy Code2084N0400X
TaxonomyNeurology Physician
License Number048766
License Number StateCT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: