Provider Demographics
NPI:1861448896
Name:MALISOVA, LARISA (DO)
Entity Type:Individual
Prefix:
First Name:LARISA
Middle Name:
Last Name:MALISOVA
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1270 E 19TH ST
Mailing Address - Street 2:APT. 6 M
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11230-5457
Mailing Address - Country:US
Mailing Address - Phone:718-338-0164
Mailing Address - Fax:
Practice Address - Street 1:420 LYNDALE AVE
Practice Address - Street 2:
Practice Address - City:STATEN ISLAND
Practice Address - State:NY
Practice Address - Zip Code:10312-6131
Practice Address - Country:US
Practice Address - Phone:718-967-5630
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-25
Last Update Date:2010-05-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY234484208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice