Provider Demographics
NPI:1972682680
Name:LAROSE, MARK R (MD)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:R
Last Name:LAROSE
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
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Other - Middle Name:
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Mailing Address - Street 1:424 W STATE HIGHWAY 5
Mailing Address - Street 2:
Mailing Address - City:WACONIA
Mailing Address - State:MN
Mailing Address - Zip Code:55387-1723
Mailing Address - Country:US
Mailing Address - Phone:952-442-4461
Mailing Address - Fax:952-442-4419
Practice Address - Street 1:424 W STATE HIGHWAY 5
Practice Address - Street 2:
Practice Address - City:WACONIA
Practice Address - State:MN
Practice Address - Zip Code:55387-1723
Practice Address - Country:US
Practice Address - Phone:952-442-4461
Practice Address - Fax:952-442-4419
Is Sole Proprietor?:No
Enumeration Date:2006-11-03
Last Update Date:2012-08-15
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MN41390207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology