Provider Demographics
NPI:1952460933
Name:CHISM BUGGS, LARISSA M (MD)
Entity Type:Individual
Prefix:DR
First Name:LARISSA
Middle Name:M
Last Name:CHISM BUGGS
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:LARISSA
Other - Middle Name:
Other - Last Name:CHISM
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:3607 S MAIN ST STE 1
Mailing Address - Street 2:
Mailing Address - City:SOUTH BEND
Mailing Address - State:IN
Mailing Address - Zip Code:46614-1723
Mailing Address - Country:US
Mailing Address - Phone:574-345-5497
Mailing Address - Fax:877-450-0123
Practice Address - Street 1:3607 S MAIN ST STE 1
Practice Address - Street 2:
Practice Address - City:SOUTH BEND
Practice Address - State:IN
Practice Address - Zip Code:46614-1723
Practice Address - Country:US
Practice Address - Phone:574-345-5497
Practice Address - Fax:877-450-0123
Is Sole Proprietor?:No
Enumeration Date:2006-12-06
Last Update Date:2024-03-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01065230A2084P0800X
IL0361636262084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry