Provider Demographics
NPI:1720019771
Name:BRUMA, LARISA M (MD)
Entity Type:Individual
Prefix:DR
First Name:LARISA
Middle Name:M
Last Name:BRUMA
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 1:1207 ROUTE 9
Mailing Address - Street 2:SUITE 11
Mailing Address - City:WAPPINGERS FALLS
Mailing Address - State:NY
Mailing Address - Zip Code:12590
Mailing Address - Country:US
Mailing Address - Phone:845-297-3200
Mailing Address - Fax:845-297-7891
Practice Address - Street 1:1207 ROUTE 9
Practice Address - Street 2:SUITE 11
Practice Address - City:WAPPINGERS FALLS
Practice Address - State:NY
Practice Address - Zip Code:12590
Practice Address - Country:US
Practice Address - Phone:845-297-3200
Practice Address - Fax:845-297-7891
Is Sole Proprietor?:No
Enumeration Date:2006-07-06
Last Update Date:2013-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI46131208100000X
MILB082656208100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & Rehabilitation
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI700E310160OtherBCBS
MI1720019771Medicaid
MI0N85680OtherMEDICARE GROUP
MI0N85680OtherMEDICARE GROUP