Provider Demographics
NPI:1578090197
Name:BRODSKY, LARISSA M (MD)
Entity Type:Individual
Prefix:
First Name:LARISSA
Middle Name:M
Last Name:BRODSKY
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:LARISSA
Other - Middle Name:
Other - Last Name:SHARMA
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 3158
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97208-3158
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:3036 NE MLK JR BLVD
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97212-3053
Practice Address - Country:US
Practice Address - Phone:503-283-3763
Practice Address - Fax:503-735-0912
Is Sole Proprietor?:No
Enumeration Date:2017-05-12
Last Update Date:2022-12-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORPG183186390200000X
ORMD200407207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program