Healthcare Provider Details

I. General information

NPI: 1922078575
Provider Name (Legal Business Name): ALLAN R LAREAU MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/25/2006
Last Update Date: 10/16/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2680 W CENTRE AVE
PORTAGE MI
49024-4828
US

IV. Provider business mailing address

2680 W CENTRE AVE
PORTAGE MI
49024-4828
US

V. Phone/Fax

Practice location:
  • Phone: 269-324-2400
  • Fax: 269-324-0450
Mailing address:
  • Phone: 269-324-2400
  • Fax: 269-324-0450

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number4301035589
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: