Provider Demographics
NPI:1780846113
Name:LAROCHE, MIRJA (MD)
Entity Type:Individual
Prefix:
First Name:MIRJA
Middle Name:
Last Name:LAROCHE
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 1:68 S SERVICE RD
Mailing Address - Street 2:SUITE 350
Mailing Address - City:MELVILLE
Mailing Address - State:NY
Mailing Address - Zip Code:11747
Mailing Address - Country:US
Mailing Address - Phone:516-945-3107
Mailing Address - Fax:516-945-3131
Practice Address - Street 1:3600 JOSEPH SIEWICK DR
Practice Address - Street 2:ANESTHESIA DEPT
Practice Address - City:FAIRFAX
Practice Address - State:VA
Practice Address - Zip Code:22033-1709
Practice Address - Country:US
Practice Address - Phone:703-391-3129
Practice Address - Fax:703-295-9369
Is Sole Proprietor?:No
Enumeration Date:2008-06-26
Last Update Date:2016-03-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101249195207L00000X
NY2774281207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA303887OtherKAISER
VA1780846113Medicaid
DCK142-0001OtherCARE FIRST
DCK142-0001OtherCARE FIRST