Provider Demographics
NPI:1508988817
Name:REIFMAN, LARISA G (MD)
Entity Type:Individual
Prefix:
First Name:LARISA
Middle Name:G
Last Name:REIFMAN
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
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Other - Credentials:
Mailing Address - Street 1:365 W PIKE ST
Mailing Address - Street 2:SUITE 201
Mailing Address - City:LAWRENCEVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30045-4862
Mailing Address - Country:US
Mailing Address - Phone:770-962-8284
Mailing Address - Fax:678-985-8007
Practice Address - Street 1:365 W PIKE ST
Practice Address - Street 2:SUITE 201
Practice Address - City:LAWRENCEVILLE
Practice Address - State:GA
Practice Address - Zip Code:30045-4862
Practice Address - Country:US
Practice Address - Phone:770-962-8284
Practice Address - Fax:678-985-8007
Is Sole Proprietor?:No
Enumeration Date:2007-04-06
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
GA24618207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
2054Medicare UPIN