Healthcare Provider Details

I. General information

NPI: 1902659253
Provider Name (Legal Business Name): KATELYN DE LARA MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/08/2024
Last Update Date: 10/02/2024
Certification Date: 10/02/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

22250 PROVIDENCE DR STE 500
SOUTHFIELD MI
48075-6213
US

IV. Provider business mailing address

22250 PROVIDENCE DR STE 500
SOUTHFIELD MI
48075-6213
US

V. Phone/Fax

Practice location:
  • Phone: 248-849-3441
  • Fax: 248-849-5826
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number4351052573
License Number StateMI
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: