Provider Demographics
NPI:1518427780
Name:WEIRICH, MARY LARISSA (MD)
Entity Type:Individual
Prefix:DR
First Name:MARY
Middle Name:LARISSA
Last Name:WEIRICH
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 1:63 CUMBERLAND RD
Mailing Address - Street 2:
Mailing Address - City:SOUTH PORTLAND
Mailing Address - State:ME
Mailing Address - Zip Code:04106-6316
Mailing Address - Country:US
Mailing Address - Phone:503-930-3413
Mailing Address - Fax:
Practice Address - Street 1:22 BRAMHALL ST
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:ME
Practice Address - Zip Code:04102-3175
Practice Address - Country:US
Practice Address - Phone:207-662-0111
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-03-22
Last Update Date:2023-03-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
GA94946207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program