Healthcare Provider Details

I. General information

NPI: 1669103941
Provider Name (Legal Business Name): GEORGE AMAURY LARA COLLADO MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/18/2022
Last Update Date: 06/24/2022
Certification Date: 06/24/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

35 MICHIGAN ST NE STE 3003
GRAND RAPIDS MI
49503-2528
US

IV. Provider business mailing address

35 MICHIGAN ST NE STE 3003
GRAND RAPIDS MI
49503-2528
US

V. Phone/Fax

Practice location:
  • Phone: 616-267-2500
  • Fax: 616-267-2501
Mailing address:
  • Phone: 616-267-2500
  • Fax: 616-267-2501

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084N0402X
TaxonomyNeurology with Special Qualifications in Child Neurology Physician
License Number4351050114
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: