Provider Demographics
NPI:1821200502
Name:LACLAIR, LARRY KEITH (MD)
Entity Type:Individual
Prefix:
First Name:LARRY
Middle Name:KEITH
Last Name:LACLAIR
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 1:25 MACMILLAN DRIVE
Mailing Address - Street 2:
Mailing Address - City:BRUNSWICK
Mailing Address - State:ME
Mailing Address - Zip Code:04011-3222
Mailing Address - Country:US
Mailing Address - Phone:207-725-8008
Mailing Address - Fax:
Practice Address - Street 1:25 MACMILLAN DRIVE
Practice Address - Street 2:
Practice Address - City:BRUNSWICK
Practice Address - State:ME
Practice Address - Zip Code:04011-3222
Practice Address - Country:US
Practice Address - Phone:207-725-8008
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-04
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ME12081207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MEB86357Medicare UPIN