Provider Demographics
NPI:1659370088
Name:LASALLE, WILLIAM B (MD)
Entity Type:Individual
Prefix:
First Name:WILLIAM
Middle Name:B
Last Name:LASALLE
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 1:5050 N CLINTON ST
Mailing Address - Street 2:
Mailing Address - City:FORT WAYNE
Mailing Address - State:IN
Mailing Address - Zip Code:46825-5822
Mailing Address - Country:US
Mailing Address - Phone:260-484-8551
Mailing Address - Fax:260-484-9603
Practice Address - Street 1:5050 N CLINTON ST
Practice Address - Street 2:
Practice Address - City:FORT WAYNE
Practice Address - State:IN
Practice Address - Zip Code:46825-5822
Practice Address - Country:US
Practice Address - Phone:260-484-8551
Practice Address - Fax:260-484-9603
Is Sole Proprietor?:No
Enumeration Date:2005-07-18
Last Update Date:2010-10-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01021529A207XS0106X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207XS0106XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryHand Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0229327Medicaid
IN058940JMedicare PIN
OH0229327Medicaid
IN058940JMedicare ID - Type Unspecified
IN100055000Medicare ID - Type Unspecified
IND94477Medicare UPIN