Healthcare Provider Details

I. General information

NPI: 1932148848
Provider Name (Legal Business Name): JOHANNA LASALA MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/06/2006
Last Update Date: 01/28/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

240 INDIAN RIVER RD BLD A STE 1
ORANGE CT
06477-3649
US

IV. Provider business mailing address

240 INDIAN RIVER RD BLD A STE 1
ORANGE CT
06477-3649
US

V. Phone/Fax

Practice location:
  • Phone: 203-795-1664
  • Fax: 203-795-1665
Mailing address:
  • Phone: 203-795-1664
  • Fax: 203-795-1665

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RH0003X
TaxonomyHematology & Oncology Physician
License Number035143
License Number StateCT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: