Provider Demographics
NPI:1417932922
Name:TEMPLE, LARISSA (MD)
Entity Type:Individual
Prefix:
First Name:LARISSA
Middle Name:
Last Name:TEMPLE
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 1:633 3RD AVE
Mailing Address - Street 2:BOX 3
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10017-6706
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1275 YORK AVE
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10021-6007
Practice Address - Country:US
Practice Address - Phone:212-639-6081
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-12-08
Last Update Date:2023-06-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY224825208C00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208C00000XAllopathic & Osteopathic PhysiciansColon & Rectal Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
H70977Medicare UPIN
3G0241Medicare ID - Type Unspecified