Provider Demographics
NPI:1306209929
Name:DYER, LARISA (DO)
Entity Type:Individual
Prefix:
First Name:LARISA
Middle Name:
Last Name:DYER
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:LARISA
Other - Middle Name:
Other - Last Name:GRINVALDS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:DO
Mailing Address - Street 1:1234 NAPIER AVE
Mailing Address - Street 2:LAKELAND HEALTH - GME
Mailing Address - City:SAINT JOSEPH
Mailing Address - State:MI
Mailing Address - Zip Code:49085-2112
Mailing Address - Country:US
Mailing Address - Phone:269-982-4941
Mailing Address - Fax:
Practice Address - Street 1:1234 NAPIER AVE
Practice Address - Street 2:LAKELAND HEALTH - GME
Practice Address - City:SAINT JOSEPH
Practice Address - State:MI
Practice Address - Zip Code:49085-2112
Practice Address - Country:US
Practice Address - Phone:269-982-4941
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-03-31
Last Update Date:2024-02-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
MI5101024654207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program