Provider Demographics
NPI:1386629285
Name:OSTROVSKAIA, LARISSA S (MD)
Entity Type:Individual
Prefix:DR
First Name:LARISSA
Middle Name:S
Last Name:OSTROVSKAIA
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:130 KINDERKAMACK RD
Mailing Address - Street 2:SUITE 200
Mailing Address - City:RIVER EDGE
Mailing Address - State:NJ
Mailing Address - Zip Code:07661
Mailing Address - Country:US
Mailing Address - Phone:201-488-2660
Mailing Address - Fax:201-489-2812
Practice Address - Street 1:30 PROSPECT AVE
Practice Address - Street 2:
Practice Address - City:HACKENSACK
Practice Address - State:NJ
Practice Address - Zip Code:07601-1914
Practice Address - Country:US
Practice Address - Phone:201-996-2200
Practice Address - Fax:201-489-2812
Is Sole Proprietor?:No
Enumeration Date:2005-12-13
Last Update Date:2007-09-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MA070889002085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ8345406Medicaid
NJG90528Medicare UPIN
NJ8345406Medicaid
NJ044904TE0Medicare PIN