Provider Demographics
NPI:1922114578
Name:LASALLE, GARRETT S (MD)
Entity Type:Individual
Prefix:
First Name:GARRETT
Middle Name:S
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 1:40 KINGS DR
Mailing Address - Street 2:
Mailing Address - City:TUXEDO PARK
Mailing Address - State:NY
Mailing Address - Zip Code:10987-5505
Mailing Address - Country:US
Mailing Address - Phone:845-524-3512
Mailing Address - Fax:845-524-3511
Practice Address - Street 1:40 KINGS DR
Practice Address - Street 2:
Practice Address - City:TUXEDO PARK
Practice Address - State:NY
Practice Address - Zip Code:10987-5505
Practice Address - Country:US
Practice Address - Phone:845-524-3512
Practice Address - Fax:845-524-3511
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-23
Last Update Date:2022-08-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KYTP781207R00000X
KY42969207R00000X
METD061090207R00000X
NY240055207R00000X, 208VP0014X
OH35.120779208VP0014X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208VP0014XAllopathic & Osteopathic PhysiciansPain MedicineInterventional Pain Medicine
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY7100079430Medicaid
KY00640022Medicare PIN
KY01065005Medicare PIN
KY01021009Medicare PIN
KY0637772Medicare PIN
KY7100079430Medicaid
KY00714063Medicare PIN
KY01022006Medicare PIN