Provider Demographics
NPI:1841799632
Name:MATOV, LARISA (PT)
Entity Type:Individual
Prefix:
First Name:LARISA
Middle Name:
Last Name:MATOV
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4000 OLD COURT RD STE 100
Mailing Address - Street 2:
Mailing Address - City:PIKESVILLE
Mailing Address - State:MD
Mailing Address - Zip Code:21208-2891
Mailing Address - Country:US
Mailing Address - Phone:410-415-0005
Mailing Address - Fax:
Practice Address - Street 1:4000 OLD COURT RD STE 100
Practice Address - Street 2:
Practice Address - City:PIKESVILLE
Practice Address - State:MD
Practice Address - Zip Code:21208-2891
Practice Address - Country:US
Practice Address - Phone:410-415-0005
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-02-07
Last Update Date:2023-09-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDA1779208100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & Rehabilitation