Provider Demographics
NPI:1225460454
Name:LARREA, DIANA ROSE (DO)
Entity Type:Individual
Prefix:DR
First Name:DIANA
Middle Name:ROSE
Last Name:LARREA
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 1:116 WRIGHT AVE
Mailing Address - Street 2:APT. L97
Mailing Address - City:STRATFORD
Mailing Address - State:NJ
Mailing Address - Zip Code:08084-1100
Mailing Address - Country:US
Mailing Address - Phone:740-856-2214
Mailing Address - Fax:
Practice Address - Street 1:42 E LAUREL RD
Practice Address - Street 2:SUITE 2100A
Practice Address - City:STRATFORD
Practice Address - State:NJ
Practice Address - Zip Code:08084-1354
Practice Address - Country:US
Practice Address - Phone:856-566-6477
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-07-30
Last Update Date:2020-03-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MB09743200207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty