Provider Demographics
NPI:1336285691
Name:LARIOSA, DIOSITA WATIN (MD,PC)
Entity Type:Individual
Prefix:
First Name:DIOSITA
Middle Name:WATIN
Last Name:LARIOSA
Suffix:
Gender:F
Credentials:MD,PC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:513 W 2ND AVE
Mailing Address - Street 2:
Mailing Address - City:ALBANY
Mailing Address - State:GA
Mailing Address - Zip Code:31701-2204
Mailing Address - Country:US
Mailing Address - Phone:229-432-7444
Mailing Address - Fax:229-432-7445
Practice Address - Street 1:513 W 2ND AVE
Practice Address - Street 2:
Practice Address - City:ALBANY
Practice Address - State:GA
Practice Address - Zip Code:31701-2204
Practice Address - Country:US
Practice Address - Phone:229-432-7444
Practice Address - Fax:229-432-7445
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-30
Last Update Date:2008-04-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA213252080A0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2080A0000XAllopathic & Osteopathic PhysiciansPediatricsAdolescent Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA000236959AOtherPEACHSTATE MEDICAID
GA336022OtherWELLCARE MEDICAID
GA000236959AMedicaid