Healthcare Provider Details

I. General information

NPI: 1992729115
Provider Name (Legal Business Name): LAFAYETTE NICHOLAS RICHMOND MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/27/2006
Last Update Date: 04/29/2020
Certification Date: 04/29/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1105 SIXTH ST
TRAVERSE CITY MI
49684-2345
US

IV. Provider business mailing address

PO BOX 30516 DEPT 9516
LANSING MI
48909
US

V. Phone/Fax

Practice location:
  • Phone: 231-935-0497
  • Fax:
Mailing address:
  • Phone: 231-935-0497
  • Fax: 231-935-0498

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2085N0700X
TaxonomyNeuroradiology Physician
License Number4301406381
License Number StateMI
# 2
Primary TaxonomyY
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License Number4301406381
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: