Provider Demographics
NPI:1003251422
Name:DUDLEY, LARISSA SOPHIA (MD)
Entity Type:Individual
Prefix:DR
First Name:LARISSA
Middle Name:SOPHIA
Last Name:DUDLEY
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 1:3426 41ST ST
Mailing Address - Street 2:APT 3F
Mailing Address - City:LONG ISLAND CITY
Mailing Address - State:NY
Mailing Address - Zip Code:11101-1351
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:201 LYONS AVE
Practice Address - Street 2:SUITE D11
Practice Address - City:NEWARK
Practice Address - State:NJ
Practice Address - Zip Code:07112-2027
Practice Address - Country:US
Practice Address - Phone:973-926-6671
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-04-30
Last Update Date:2017-12-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
FLME131434207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program