=====================================================
General NPI Number Information
=====================================================
NPI Number | 1568446888
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | GWENDOLYN L. LAVALAIS, M.D., P.A.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/30/2005
-----------------------------------------------------
Last Update Date | 07/21/2022
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3555 STAGG DRIVE
-----------------------------------------------------
City | BEAUMONT
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 77701
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 409-212-5930
-----------------------------------------------------
Fax | 409-212-5931
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 3555 STAGG DRIVE
-----------------------------------------------------
City | BEAUMONT
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 77701
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 409-212-5930
-----------------------------------------------------
Fax | 409-212-5931
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | DR. GWENDOLYN L LAVALAIS
-----------------------------------------------------
Credential | MD
-----------------------------------------------------
Telephone | 409-212-5930
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207RX0202X
-----------------------------------------------------
Taxonomy Name | Medical Oncology Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State | TX
-----------------------------------------------------