Healthcare Provider Details

I. General information

NPI: 1568921302
Provider Name (Legal Business Name): RYAN LAROCHELLE M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/19/2019
Last Update Date: 09/15/2025
Certification Date: 09/15/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

15 LOWELL ST
PORTLAND ME
04102-2792
US

IV. Provider business mailing address

2 OAK GLEN CT
MADISON WI
53717-1605
US

V. Phone/Fax

Practice location:
  • Phone: 207-774-8277
  • Fax:
Mailing address:
  • Phone: 207-852-1441
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number StateNULL
# 2
Primary TaxonomyY
Taxonomy Code207W00000X
TaxonomyOphthalmology Physician
License NumberMD28531
License Number StateME
# 3
Primary TaxonomyN
Taxonomy Code207W00000X
TaxonomyOphthalmology Physician
License Number81645
License Number StateWI
# 4
Primary TaxonomyN
Taxonomy Code207WX0200X
TaxonomyOphthalmic Plastic and Reconstructive Surgery Physician
License Number81645
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: