Healthcare Provider Details

I. General information

NPI: 1992915805
Provider Name (Legal Business Name): DR. JUSTIN MARK LAREAU
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/22/2007
Last Update Date: 12/07/2021
Certification Date: 12/07/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1010 EXECUTIVE DR SUITE 250
WESTMONT IL
60559-6135
US

IV. Provider business mailing address

550 W OGDEN AVE
HINSDALE IL
60521-3186
US

V. Phone/Fax

Practice location:
  • Phone: 630-920-2350
  • Fax: 630-920-9381
Mailing address:
  • Phone: 630-323-6116
  • Fax: 630-323-6169

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207X00000X
TaxonomyOrthopaedic Surgery Physician
License Number036124358
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: