Provider Demographics
NPI:1871551226
Name:FALLAT, LAWRENCE M (DPM)
Entity type:Individual
Prefix:
First Name:LAWRENCE
Middle Name:M
Last Name:FALLAT
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:20555 ECORSE RD
Mailing Address - Street 2:
Mailing Address - City:TAYLOR
Mailing Address - State:MI
Mailing Address - Zip Code:48180-1992
Mailing Address - Country:US
Mailing Address - Phone:313-389-2288
Mailing Address - Fax:
Practice Address - Street 1:20555 ECORSE RD
Practice Address - Street 2:
Practice Address - City:TAYLOR
Practice Address - State:MI
Practice Address - Zip Code:48180-1992
Practice Address - Country:US
Practice Address - Phone:313-389-2288
Practice Address - Fax:313-389-2286
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-03
Last Update Date:2014-10-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5901000848213ES0103X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI0M99280001Medicare PIN
T34418Medicare UPIN
MI0M99280001Medicare PIN