Provider Demographics
NPI:1336127620
Name:LASALLE, MICHAEL JOHN (DPM)
Entity Type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:JOHN
Last Name:LASALLE
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5 CREST CIRCLE DRIVE
Mailing Address - Street 2:
Mailing Address - City:MILLSTONE
Mailing Address - State:NJ
Mailing Address - Zip Code:08510
Mailing Address - Country:US
Mailing Address - Phone:732-625-3889
Mailing Address - Fax:732-625-8389
Practice Address - Street 1:THE ORCHARD SHOPPING PLAZA
Practice Address - Street 2:24 STATE HWY 34 SOUTH, 2ND LEVEL
Practice Address - City:COLTS NECK
Practice Address - State:NJ
Practice Address - Zip Code:07722-0000
Practice Address - Country:US
Practice Address - Phone:732-625-3889
Practice Address - Fax:732-625-8389
Is Sole Proprietor?:Yes
Enumeration Date:2006-01-06
Last Update Date:2024-01-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJMD2460213ES0103X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ7915802Medicaid
NJU69685Medicare UPIN
NJ006893Medicare ID - Type Unspecified