Provider Demographics
NPI: | 1760484315 |
---|---|
Name: | LARREATEGUI, PATRICK ALBERTO (DO) |
Entity Type: | Individual |
Prefix: | |
First Name: | PATRICK |
Middle Name: | ALBERTO |
Last Name: | LARREATEGUI |
Suffix: | |
Gender: | M |
Credentials: | DO |
Other - Prefix: | |
Other - First Name: | |
Other - Middle Name: | |
Other - Last Name: | |
Other - Suffix: | |
Other - Last Name Type: | |
Other - Credentials: | |
Mailing Address - Street 1: | 3130 N COUNTY ROAD 25A |
Mailing Address - Street 2: | STE 214 |
Mailing Address - City: | TROY |
Mailing Address - State: | OH |
Mailing Address - Zip Code: | 45373-1337 |
Mailing Address - Country: | US |
Mailing Address - Phone: | 937-332-8777 |
Mailing Address - Fax: | 937-332-8773 |
Practice Address - Street 1: | 3130 N COUNTY ROAD 25A |
Practice Address - Street 2: | STE 214 |
Practice Address - City: | TROY |
Practice Address - State: | OH |
Practice Address - Zip Code: | 45373-1337 |
Practice Address - Country: | US |
Practice Address - Phone: | 937-332-8777 |
Practice Address - Fax: | 937-332-8773 |
Is Sole Proprietor?: | No |
Enumeration Date: | 2005-08-12 |
Last Update Date: | 2017-04-25 |
Deactivation Date: | |
Deactivation Code: | |
Reactivation Date: |
Provider Licenses
State | License ID | Taxonomies |
---|---|---|
OH | 34008069L | 208600000X |
Provider Taxonomies
Primary? | Code | Type | Classification | Specialization |
---|---|---|---|---|
Yes | 208600000X | Allopathic & Osteopathic Physicians | Surgery |
Provider Identifiers
State | Identifier ID | ID Type | Issuer |
---|---|---|---|
OH | 2500761 | Medicaid | |
OH | 0240840 | Other | MEDICARE GROUP # |
MI9912194 | Other | MEDICARE GROUP # | |
MI9912194 | Other | MEDICARE GROUP # | |
H90988 | Medicare UPIN | ||
OH | 2500761 | Medicaid |