Healthcare Provider Details

I. General information

NPI: 1356804512
Provider Name (Legal Business Name): MICHAEL STEPHEN LA SALA DO, MS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/12/2019
Last Update Date: 06/27/2024
Certification Date: 06/27/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

777 GLADES RD
BOCA RATON FL
33431-6496
US

IV. Provider business mailing address

1730 LAKESHORE DR
WESTON FL
33326-2374
US

V. Phone/Fax

Practice location:
  • Phone: 561-297-4828
  • Fax:
Mailing address:
  • Phone: 954-850-8781
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number1356804512
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: