Healthcare Provider Details

I. General information

NPI: 1093455313
Provider Name (Legal Business Name): ELIZABETH ANNE LAVALLEY OTERSEN MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: ELIZABETH ANNE LA VALLEY

II. Dates (important events)

Enumeration Date: 04/01/2022
Last Update Date: 04/06/2026
Certification Date: 04/06/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

103 THOMPSON ST STE 100
LEXINGTON SC
29072-2543
US

IV. Provider business mailing address

100 N ACADEMY AVE
DANVILLE PA
17822-4903
US

V. Phone/Fax

Practice location:
  • Phone: 803-359-8855
  • Fax: 803-359-1257
Mailing address:
  • Phone: 570-271-5600
  • Fax: 570-271-5851

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number96220
License Number StateSC
# 2
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberMD489169
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: