Provider Demographics
NPI:1609825736
Name:KHESINA, LARISA (MD)
Entity Type:Individual
Prefix:
First Name:LARISA
Middle Name:
Last Name:KHESINA
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 1:15034 UNION TPKE
Mailing Address - Street 2:
Mailing Address - City:FLUSHING
Mailing Address - State:NY
Mailing Address - Zip Code:11367-3928
Mailing Address - Country:US
Mailing Address - Phone:718-380-0011
Mailing Address - Fax:718-820-0841
Practice Address - Street 1:15034 UNION TPKE
Practice Address - Street 2:
Practice Address - City:FLUSHING
Practice Address - State:NY
Practice Address - Zip Code:11367-3928
Practice Address - Country:US
Practice Address - Phone:718-380-0011
Practice Address - Fax:718-820-0841
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-08
Last Update Date:2013-12-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY203378207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01676517Medicaid
NY01676517Medicaid
NY02259Medicare PIN