Provider Demographics
NPI:1497860670
Name:LAROSA, DAVID JR (MD)
Entity Type:Individual
Prefix:DR
First Name:DAVID
Middle Name:
Last Name:LAROSA
Suffix:JR
Gender:M
Credentials:MD
Other - Prefix:DR
Other - First Name:DAVID
Other - Middle Name:
Other - Last Name:LAROSA
Other - Suffix:JR
Other - Last Name Type:Professional Name
Other - Credentials:MD
Mailing Address - Street 1:PO BOX 1810
Mailing Address - Street 2:
Mailing Address - City:GULFPORT
Mailing Address - State:MS
Mailing Address - Zip Code:39502-1810
Mailing Address - Country:US
Mailing Address - Phone:228-864-8454
Mailing Address - Fax:228-865-1457
Practice Address - Street 1:1340 BROAD AVE
Practice Address - Street 2:SUITE 310
Practice Address - City:GULFPORT
Practice Address - State:MS
Practice Address - Zip Code:39501-2404
Practice Address - Country:US
Practice Address - Phone:228-864-6629
Practice Address - Fax:228-864-6669
Is Sole Proprietor?:No
Enumeration Date:2006-08-20
Last Update Date:2014-07-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS16217207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS00120612Medicaid
MS00120612Medicaid
MS512I110236Medicare PIN
MS302I115954Medicare PIN
MS110184134Medicare PIN
MS110001172Medicare PIN
MS00120612Medicaid