Healthcare Provider Details

I. General information

NPI: 1114952991
Provider Name (Legal Business Name): LUCIEN R. OUELLETTE M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/11/2006
Last Update Date: 02/21/2025
Certification Date: 02/21/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1409 S MAIN STREET
FARMVILLE VA
23901-2531
US

IV. Provider business mailing address

P. O. BOX 715868
PHILADELPHIA PA
19171-5868
US

V. Phone/Fax

Practice location:
  • Phone: 434-207-5170
  • Fax: 434-485-8599
Mailing address:
  • Phone: 804-327-9242
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2080S0010X
TaxonomyPediatric Sports Medicine Physician
License NumberMD16785
License Number StateME
# 2
Primary TaxonomyY
Taxonomy Code2080S0010X
TaxonomyPediatric Sports Medicine Physician
License Number0101058044
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: