Provider Demographics
NPI:1154483634
Name:LARRAIN, RICARDO JOSE (MD)
Entity Type:Individual
Prefix:
First Name:RICARDO
Middle Name:JOSE
Last Name:LARRAIN
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 1:800 W PLYMOUTH AVE
Mailing Address - Street 2:
Mailing Address - City:DELAND
Mailing Address - State:FL
Mailing Address - Zip Code:32720-3271
Mailing Address - Country:US
Mailing Address - Phone:386-736-1404
Mailing Address - Fax:386-736-1423
Practice Address - Street 1:800 W PLYMOUTH AVE
Practice Address - Street 2:
Practice Address - City:DELAND
Practice Address - State:FL
Practice Address - Zip Code:32720-3271
Practice Address - Country:US
Practice Address - Phone:386-736-1404
Practice Address - Fax:386-736-1423
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-14
Last Update Date:2012-06-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME0062589207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL370830600Medicaid
FL370830600Medicaid
17774Medicare ID - Type Unspecified