Provider Demographics
NPI:1649379181
Name:LARISA KLOTS DO INC
Entity Type:Organization
Organization Name:LARISA KLOTS DO INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:LARISA
Authorized Official - Middle Name:
Authorized Official - Last Name:KLOTS
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:732-257-8442
Mailing Address - Street 1:11 BUFFALO RUN
Mailing Address - Street 2:
Mailing Address - City:E BRUNSWICK
Mailing Address - State:NJ
Mailing Address - Zip Code:08816-4078
Mailing Address - Country:US
Mailing Address - Phone:732-254-1114
Mailing Address - Fax:732-254-2247
Practice Address - Street 1:B3 BRIER HILL CT
Practice Address - Street 2:
Practice Address - City:E BRUNSWICK
Practice Address - State:NJ
Practice Address - Zip Code:08816-3330
Practice Address - Country:US
Practice Address - Phone:732-254-1114
Practice Address - Fax:732-254-2247
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-21
Last Update Date:2013-09-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJMB71358207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ088830Medicare ID - Type Unspecified
NJG90998Medicare UPIN