Provider Demographics
NPI:1376575282
Name:DOMINY, LARISSA F (DO)
Entity Type:Individual
Prefix:DR
First Name:LARISSA
Middle Name:F
Last Name:DOMINY
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
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Mailing Address - Street 1:102 SHETLAND WAY
Mailing Address - Street 2:
Mailing Address - City:COLLEGEVILLE
Mailing Address - State:PA
Mailing Address - Zip Code:19426-2854
Mailing Address - Country:US
Mailing Address - Phone:610-409-8147
Mailing Address - Fax:610-409-9319
Practice Address - Street 1:555 SOUTH SECOND AVENUE
Practice Address - Street 2:BUILDING B, SUITE 200
Practice Address - City:COLLEGEVILLE
Practice Address - State:PA
Practice Address - Zip Code:19426
Practice Address - Country:US
Practice Address - Phone:610-409-8050
Practice Address - Fax:610-409-8075
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-07
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
PAOS-009162L208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
PAG51642Medicare UPIN