Provider Demographics
NPI:1225005226
Name:LARISCY, CRAIG (MD)
Entity Type:Individual
Prefix:
First Name:CRAIG
Middle Name:
Last Name:LARISCY
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 1:1125 BARTOW RD
Mailing Address - Street 2:SUITE 101
Mailing Address - City:LAKELAND
Mailing Address - State:FL
Mailing Address - Zip Code:33801-5852
Mailing Address - Country:US
Mailing Address - Phone:863-683-7171
Mailing Address - Fax:863-687-0742
Practice Address - Street 1:1125 BARTOW RD
Practice Address - Street 2:SUITE 101
Practice Address - City:LAKELAND
Practice Address - State:FL
Practice Address - Zip Code:33801-5852
Practice Address - Country:US
Practice Address - Phone:863-683-7171
Practice Address - Fax:863-687-0742
Is Sole Proprietor?:No
Enumeration Date:2006-03-08
Last Update Date:2015-12-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME-0077072207ZP0102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207ZP0102XAllopathic & Osteopathic PhysiciansPathologyAnatomic Pathology & Clinical Pathology
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL257612100Medicaid
FLE2487ZMedicare ID - Type Unspecified
FL257612100Medicaid