Provider Demographics
NPI:1295766137
Name:PINNOCK, LASCELLES (MD)
Entity type:Individual
Prefix:DR
First Name:LASCELLES
Middle Name:
Last Name:PINNOCK
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 1:14575 SOUTHFIELD RD
Mailing Address - Street 2:
Mailing Address - City:ALLEN PARK
Mailing Address - State:MI
Mailing Address - Zip Code:48101
Mailing Address - Country:US
Mailing Address - Phone:313-381-5170
Mailing Address - Fax:313-381-8790
Practice Address - Street 1:14575 SOUTHFIELD RD
Practice Address - Street 2:
Practice Address - City:ALLEN PARK
Practice Address - State:MI
Practice Address - Zip Code:48101
Practice Address - Country:US
Practice Address - Phone:313-381-5170
Practice Address - Fax:313-381-8790
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-06
Last Update Date:2010-12-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MILP042960207Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Y00000XAllopathic & Osteopathic PhysiciansOtolaryngology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI0255787002OtherCIGNA
MI4033934OtherAETNA
MI13242OtherWELLNESS -CHSD
MI21165OtherOMNI HMO
MI046OtherHEALTH PLUS
MI2110638-10Medicaid
MI125274OtherCARE CHOICES
MI4440296OtherTEAMSTERS
MI48254OtherOMNI CARE CONVENTRY
MIOH23634OtherBLUE CROSS BLUE SHIELD
MI81165OtherOMNI POS
MI000000004774OtherCAPE HEALTH
MI046OtherHEALTH PLUS
MI48254OtherOMNI CARE CONVENTRY