Provider Demographics
NPI:1477737666
Name:MIKHAYLOV, LARISA (MD)
Entity Type:Individual
Prefix:
First Name:LARISA
Middle Name:
Last Name:MIKHAYLOV
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:P.O BOX 798
Mailing Address - Street 2:
Mailing Address - City:ROCKVILLE CENTRE
Mailing Address - State:NY
Mailing Address - Zip Code:11571
Mailing Address - Country:US
Mailing Address - Phone:516-705-1353
Mailing Address - Fax:516-705-3575
Practice Address - Street 1:1000 N. VILLAGE AVENUE
Practice Address - Street 2:
Practice Address - City:ROCKVILLE CENTRE
Practice Address - State:NY
Practice Address - Zip Code:11571
Practice Address - Country:US
Practice Address - Phone:516-705-1353
Practice Address - Fax:516-705-3575
Is Sole Proprietor?:No
Enumeration Date:2007-12-24
Last Update Date:2008-04-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY167427208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY167427OtherLICENSE