Healthcare Provider Details

I. General information

NPI: 1285676205
Provider Name (Legal Business Name): GARY JAY LAVALLEY O.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

Provider Other Name: HENRYETTA EYE CENTER

II. Dates (important events)

Enumeration Date: 06/12/2006
Last Update Date: 09/13/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

900 W MAIN ST
HENRYETTA OK
74437-4252
US

IV. Provider business mailing address

900 W MAIN ST
HENRYETTA OK
74437-4252
US

V. Phone/Fax

Practice location:
  • Phone: 918-652-2345
  • Fax: 918-652-2537
Mailing address:
  • Phone: 918-652-2345
  • Fax: 918-652-2537

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number2071
License Number StateOK

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: