Provider Demographics
NPI:1124129119
Name:LASSITER, TALLY EDWARD JR (MD)
Entity type:Individual
Prefix:
First Name:TALLY
Middle Name:EDWARD
Last Name:LASSITER
Suffix:JR
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:PO BOX 725
Mailing Address - Street 2:
Mailing Address - City:COOPERSTOWN
Mailing Address - State:NY
Mailing Address - Zip Code:13326-0725
Mailing Address - Country:US
Mailing Address - Phone:607-433-6314
Mailing Address - Fax:607-433-6331
Practice Address - Street 1:1 ASSOCIATE DR
Practice Address - Street 2:
Practice Address - City:ONEONTA
Practice Address - State:NY
Practice Address - Zip Code:13820-2266
Practice Address - Country:US
Practice Address - Phone:607-433-6314
Practice Address - Fax:607-433-6331
Is Sole Proprietor?:No
Enumeration Date:2006-09-25
Last Update Date:2012-06-12
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
NY256321207XX0005X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207XX0005XAllopathic & Osteopathic PhysiciansOrthopaedic SurgerySports Medicine