Provider Demographics
NPI:1134191539
Name:MALYKH, LARISA (MD)
Entity type:Individual
Prefix:DR
First Name:LARISA
Middle Name:
Last Name:MALYKH
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 1:6100 SAINT JOHNS AVE
Mailing Address - Street 2:SUTE 4(D)
Mailing Address - City:PALATKA
Mailing Address - State:FL
Mailing Address - Zip Code:32177-3844
Mailing Address - Country:US
Mailing Address - Phone:386-329-3939
Mailing Address - Fax:386-329-8990
Practice Address - Street 1:6100 SAINT JOHNS AVE
Practice Address - Street 2:SUITE 4(D)
Practice Address - City:PALATKA
Practice Address - State:FL
Practice Address - Zip Code:32177-3844
Practice Address - Country:US
Practice Address - Phone:386-329-3939
Practice Address - Fax:386-329-8990
Is Sole Proprietor?:No
Enumeration Date:2006-02-02
Last Update Date:2012-03-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME79246207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL49324WMedicare PIN
H08673Medicare UPIN