Healthcare Provider Details

I. General information

NPI: 1609283936
Provider Name (Legal Business Name): LARA MARIEL OSETINSKY M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: L. MARIEL OSETINSKY M.D.

II. Dates (important events)

Enumeration Date: 07/18/2014
Last Update Date: 07/07/2026
Certification Date: 07/07/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4069 LAKE DR SE STE 315
GRAND RAPIDS MI
49546-8816
US

IV. Provider business mailing address

100 MICHIGAN ST NE MC 845
GRAND RAPIDS MI
49503-2560
US

V. Phone/Fax

Practice location:
  • Phone: 616-267-7758
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Y00000X
TaxonomyOtolaryngology Physician
License Number4301517179
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: