Provider Demographics
NPI:1003894221
Name:LAAKSO, LIISA L (DO)
Entity Type:Individual
Prefix:DR
First Name:LIISA
Middle Name:L
Last Name:LAAKSO
Suffix:
Gender:F
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:PO BOX 9007
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTESVILLE
Mailing Address - State:VA
Mailing Address - Zip Code:22906-9007
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:8700 SUDLEY RD
Practice Address - Street 2:
Practice Address - City:MANASSAS
Practice Address - State:VA
Practice Address - Zip Code:20110-4418
Practice Address - Country:US
Practice Address - Phone:703-369-8073
Practice Address - Fax:703-369-8032
Is Sole Proprietor?:No
Enumeration Date:2006-01-06
Last Update Date:2024-02-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL0360580152085R0202X
VA01022060112085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILCB4562OtherTRAVELERS MEDICARE GRP
IL01615363OtherBC GROUP
IL036058015Medicaid
ILP00386472OtherTRAVLERS INDIVIDUAL PIN
ILP00386472OtherTRAVLERS INDIVIDUAL PIN
IL603160Medicare ID - Type UnspecifiedGROUP
IL769450Medicare ID - Type UnspecifiedMEDICARE GROUP
ILCB4562OtherTRAVELERS MEDICARE GRP
ILE03793Medicare UPIN
ILP00057357Medicare ID - Type UnspecifiedTRAVELERS MEDICARE
ILP00177596Medicare ID - Type UnspecifiedTRAVELERS MEDICARE
IL036058015Medicaid