Provider Demographics
NPI:1376639948
Name:LASSERE, RICHARD JOHN (MD)
Entity Type:Individual
Prefix:
First Name:RICHARD
Middle Name:JOHN
Last Name:LASSERE
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:PO BOX 27128
Mailing Address - Street 2:
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84127-0128
Mailing Address - Country:US
Mailing Address - Phone:208-251-9093
Mailing Address - Fax:
Practice Address - Street 1:353 N. 4TH 102
Practice Address - Street 2:
Practice Address - City:POCATELLO
Practice Address - State:ID
Practice Address - Zip Code:83201
Practice Address - Country:US
Practice Address - Phone:208-478-7900
Practice Address - Fax:208-479-7901
Is Sole Proprietor?:No
Enumeration Date:2006-10-04
Last Update Date:2016-02-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT9651486-1205207QG0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207QG0300XAllopathic & Osteopathic PhysiciansFamily MedicineGeriatric Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID003792800Medicaid
ID49726OtherBLUE CROSS
IDB64354Medicare UPIN
ID003792800Medicaid