Provider Demographics
NPI:1982634135
Name:COLONBENGOA, LARISSA M
Entity Type:Individual
Prefix:
First Name:LARISSA
Middle Name:M
Last Name:COLONBENGOA
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8888 SW 24TH ST
Mailing Address - Street 2:
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33165-2008
Mailing Address - Country:US
Mailing Address - Phone:305-642-5366
Mailing Address - Fax:
Practice Address - Street 1:8888 SW 24TH ST
Practice Address - Street 2:
Practice Address - City:MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33165-2008
Practice Address - Country:US
Practice Address - Phone:305-642-5366
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-04
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME87982207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLI15352Medicare UPIN
FLU3056ZMedicare ID - Type Unspecified