Provider Demographics
NPI:1083775407
Name:DALLA VECCHIA, LAURA KATHLEEN (MD)
Entity Type:Individual
Prefix:DR
First Name:LAURA
Middle Name:KATHLEEN
Last Name:DALLA VECCHIA
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:43331 COMMONS DR
Mailing Address - Street 2:
Mailing Address - City:CLINTON TOWNSHIP
Mailing Address - State:MI
Mailing Address - Zip Code:48038-1109
Mailing Address - Country:US
Mailing Address - Phone:586-263-5410
Mailing Address - Fax:586-263-7131
Practice Address - Street 1:43331 COMMONS DR
Practice Address - Street 2:
Practice Address - City:CLINTON TOWNSHIP
Practice Address - State:MI
Practice Address - Zip Code:48038-1109
Practice Address - Country:US
Practice Address - Phone:586-263-5410
Practice Address - Fax:586-263-7131
Is Sole Proprietor?:No
Enumeration Date:2006-12-12
Last Update Date:2020-12-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301075676208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI1316031339OtherGROUP NPI
MI4856287Medicaid
MI0M53560006Medicare ID - Type Unspecified
MIH16270Medicare UPIN