Provider Demographics
NPI:1598747925
Name:BUCCOLO, LARISSA SARAH (MD)
Entity Type:Individual
Prefix:DR
First Name:LARISSA
Middle Name:SARAH
Last Name:BUCCOLO
Suffix:
Gender:F
Credentials:MD
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Other - Credentials:
Mailing Address - Street 1:820 PRUDENTIAL DR
Mailing Address - Street 2:STE 713
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32207-8210
Mailing Address - Country:US
Mailing Address - Phone:904-396-5682
Mailing Address - Fax:904-346-0864
Practice Address - Street 1:820 PRUDENTIAL DR
Practice Address - Street 2:STE 713
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32207-8210
Practice Address - Country:US
Practice Address - Phone:904-396-5682
Practice Address - Fax:904-346-0864
Is Sole Proprietor?:No
Enumeration Date:2005-11-21
Last Update Date:2016-05-28
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
FLME 103556207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine