Provider Demographics
NPI:1679564330
Name:LAVALLEE, MARK EDWARD (MD)
Entity type:Individual
Prefix:DR
First Name:MARK
Middle Name:EDWARD
Last Name:LAVALLEE
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2005 TECHNOLOGY PKWY STE 100
Mailing Address - Street 2:
Mailing Address - City:MECHANICSBURG
Mailing Address - State:PA
Mailing Address - Zip Code:17050-9413
Mailing Address - Country:US
Mailing Address - Phone:717-791-2620
Mailing Address - Fax:717-791-2621
Practice Address - Street 1:2005 TECHNOLOGY PKWY STE 100
Practice Address - Street 2:
Practice Address - City:MECHANICSBURG
Practice Address - State:PA
Practice Address - Zip Code:17050-9413
Practice Address - Country:US
Practice Address - Phone:717-791-2620
Practice Address - Fax:717-791-2621
Is Sole Proprietor?:No
Enumeration Date:2005-11-02
Last Update Date:2024-04-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD060390L207Q00000X, 207QS0010X
IN01049328A207QS0010X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207QS0010XAllopathic & Osteopathic PhysiciansFamily MedicineSports Medicine
No207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200198600Medicaid
PA002980953OtherHIGHMARK BLUE SHIELD
MD068809600Medicaid
PA102855069Medicaid
IN200198600Medicaid
PA311152FLTMedicare PIN
ING79848Medicare UPIN
MD068809600Medicaid
IN233530AMedicare PIN