Provider Demographics
NPI:1760484315
Name:LARREATEGUI, PATRICK ALBERTO (DO)
Entity type:Individual
Prefix:
First Name:PATRICK
Middle Name:ALBERTO
Last Name:LARREATEGUI
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3130 N COUNTY ROAD 25A
Mailing Address - Street 2:STE 214
Mailing Address - City:TROY
Mailing Address - State:OH
Mailing Address - Zip Code:45373-1337
Mailing Address - Country:US
Mailing Address - Phone:937-332-8777
Mailing Address - Fax:937-332-8773
Practice Address - Street 1:3130 N COUNTY ROAD 25A
Practice Address - Street 2:STE 214
Practice Address - City:TROY
Practice Address - State:OH
Practice Address - Zip Code:45373-1337
Practice Address - Country:US
Practice Address - Phone:937-332-8777
Practice Address - Fax:937-332-8773
Is Sole Proprietor?:No
Enumeration Date:2005-08-12
Last Update Date:2017-04-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH34008069L208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2500761Medicaid
OH0240840OtherMEDICARE GROUP #
MI9912194OtherMEDICARE GROUP #
MI9912194OtherMEDICARE GROUP #
H90988Medicare UPIN
OH2500761Medicaid