Provider Demographics
NPI:1821162769
Name:MALMSTADT, LARISSA (MD)
Entity Type:Individual
Prefix:DR
First Name:LARISSA
Middle Name:
Last Name:MALMSTADT
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 1:3365 S 103RD ST
Mailing Address - Street 2:SUITE 100
Mailing Address - City:MILWAUKEE
Mailing Address - State:WI
Mailing Address - Zip Code:53227-4161
Mailing Address - Country:US
Mailing Address - Phone:414-321-3951
Mailing Address - Fax:414-321-8307
Practice Address - Street 1:3365 S 103RD ST
Practice Address - Street 2:SUITE 100
Practice Address - City:MILWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53227-4161
Practice Address - Country:US
Practice Address - Phone:414-321-3951
Practice Address - Fax:414-321-8307
Is Sole Proprietor?:No
Enumeration Date:2006-11-20
Last Update Date:2011-12-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI48877-020208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI1821162769Medicaid