Provider Demographics
NPI:1932148848
Name:LASALA, JOHANNA (MD)
Entity Type:Individual
Prefix:DR
First Name:JOHANNA
Middle Name:
Last Name:LASALA
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:240 INDIAN RIVER RD
Mailing Address - Street 2:BLD A STE 1
Mailing Address - City:ORANGE
Mailing Address - State:CT
Mailing Address - Zip Code:06477-3649
Mailing Address - Country:US
Mailing Address - Phone:203-795-1664
Mailing Address - Fax:203-795-1665
Practice Address - Street 1:240 INDIAN RIVER RD
Practice Address - Street 2:BLD A STE 1
Practice Address - City:ORANGE
Practice Address - State:CT
Practice Address - Zip Code:06477-3649
Practice Address - Country:US
Practice Address - Phone:203-795-1664
Practice Address - Fax:203-795-1665
Is Sole Proprietor?:No
Enumeration Date:2006-06-06
Last Update Date:2013-01-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT035143207RH0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RH0003XAllopathic & Osteopathic PhysiciansInternal MedicineHematology & Oncology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT001351436Medicaid
CT830000175Medicare PIN
CT001351436Medicaid
CT830000046Medicare ID - Type Unspecified