Healthcare Provider Details

I. General information

NPI: 1336136761
Provider Name (Legal Business Name): ERICK JP LAVALLEE MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/30/2005
Last Update Date: 01/15/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

44 MAIN ST SUITE 200
RICHFORD VT
05476-1153
US

IV. Provider business mailing address

44 MAIN ST STE 200
RICHFORD VT
05476-1141
CA

V. Phone/Fax

Practice location:
  • Phone: 802-255-5500
  • Fax: 802-255-5509
Mailing address:
  • Phone: 802-255-5500
  • Fax: 802-255-5589

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number042-0010825
License Number StateVT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: