Healthcare Provider Details

I. General information

NPI: 1154373405
Provider Name (Legal Business Name): JOHN HOWARD LAVALETTE MD
Entity Type: Individual
Gender: Male
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 05/16/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

31 SYCAMORE RD
GLASTONBURY CT
06033
US

IV. Provider business mailing address

546 CROMWELL AVE
ROCKY HILL CT
06067
US

V. Phone/Fax

Practice location:
  • Phone: 860-721-7561
  • Fax: 860-721-9199
Mailing address:
  • Phone: 860-721-7561
  • Fax: 860-721-9199

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number037023
License Number StateCT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: