Provider Demographics
NPI:1275521254
Name:LASKE, DOUGLAS W (MD)
Entity Type:Individual
Prefix:
First Name:DOUGLAS
Middle Name:W
Last Name:LASKE
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2510 MARYLAND RD STE 185
Mailing Address - Street 2:
Mailing Address - City:WILLOW GROVE
Mailing Address - State:PA
Mailing Address - Zip Code:19090-1134
Mailing Address - Country:US
Mailing Address - Phone:215-657-5886
Mailing Address - Fax:215-657-9996
Practice Address - Street 1:2510 MARYLAND RD STE 185
Practice Address - Street 2:
Practice Address - City:WILLOW GROVE
Practice Address - State:PA
Practice Address - Zip Code:19090-1134
Practice Address - Country:US
Practice Address - Phone:215-657-5886
Practice Address - Fax:215-657-9996
Is Sole Proprietor?:No
Enumeration Date:2005-10-12
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD055501L207T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207T00000XAllopathic & Osteopathic PhysiciansNeurological Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA0015165680001Medicaid
PA670001Medicare PIN
PA0015165680001Medicaid
G03384Medicare UPIN