Provider Demographics
NPI:1063528883
Name:LAROQUE, MICHAEL J (MD)
Entity type:Individual
Prefix:
First Name:MICHAEL
Middle Name:J
Last Name:LAROQUE
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 1:40520 COUNTY HIGHWAY 34
Mailing Address - Street 2:
Mailing Address - City:OGEMA
Mailing Address - State:MN
Mailing Address - Zip Code:56569-9612
Mailing Address - Country:US
Mailing Address - Phone:218-983-4300
Mailing Address - Fax:218-983-6394
Practice Address - Street 1:40520 COUNTY HIGHWAY 34
Practice Address - Street 2:
Practice Address - City:OGEMA
Practice Address - State:MN
Practice Address - Zip Code:56569-9612
Practice Address - Country:US
Practice Address - Phone:218-983-4300
Practice Address - Fax:218-983-6394
Is Sole Proprietor?:No
Enumeration Date:2006-08-22
Last Update Date:2012-02-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ND7952207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
AKMD2854Medicaid
AKMD2854Medicaid
8HL307Medicare UPIN
8HL305Medicare UPIN
AKG69935Medicare UPIN
AK8EZ60EMedicare ID - Type Unspecified