Provider Demographics
NPI:1891769808
Name:DI LAURO, MICHELE ALISA (MD)
Entity Type:Individual
Prefix:DR
First Name:MICHELE
Middle Name:ALISA
Last Name:DI LAURO
Suffix:
Gender:F
Credentials:MD
Other - Prefix:DR
Other - First Name:MICHELE
Other - Middle Name:A
Other - Last Name:DI LAURO
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MD
Mailing Address - Street 1:1800 W. CHARLESTON BLVD. STE. 508
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89102
Mailing Address - Country:US
Mailing Address - Phone:702-383-2688
Mailing Address - Fax:702-671-6595
Practice Address - Street 1:4180 S. RAINBOW BLVD. SUITE 810
Practice Address - Street 2:
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89103
Practice Address - Country:US
Practice Address - Phone:702-383-3645
Practice Address - Fax:702-227-8429
Is Sole Proprietor?:No
Enumeration Date:2006-02-15
Last Update Date:2019-03-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD437131207Q00000X, 207QA0401X
NJ25MA06943800207Q00000X, 207QA0401X
NV10917207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No207QA0401XAllopathic & Osteopathic PhysiciansFamily MedicineAddiction Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NV100503279Medicaid
NV100503659Medicaid
NV100503279Medicaid