Provider Demographics
NPI:1134362718
Name:LARISCY, DAVID WAYNE (MD)
Entity type:Individual
Prefix:DR
First Name:DAVID
Middle Name:WAYNE
Last Name:LARISCY
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
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Other - Credentials:
Mailing Address - Street 1:103 WINDY HILL CT
Mailing Address - Street 2:
Mailing Address - City:STATESBORO
Mailing Address - State:GA
Mailing Address - Zip Code:30458-9139
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1058 BERMUDA RUN
Practice Address - Street 2:
Practice Address - City:STATESBORO
Practice Address - State:GA
Practice Address - Zip Code:30458-0858
Practice Address - Country:US
Practice Address - Phone:912-243-9274
Practice Address - Fax:912-341-6513
Is Sole Proprietor?:Yes
Enumeration Date:2009-04-13
Last Update Date:2023-03-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA074285207UN0901X, 207RC0000X
KY56424208M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
No207UN0901XAllopathic & Osteopathic PhysiciansNuclear MedicineNuclear Cardiology
No208M00000XAllopathic & Osteopathic PhysiciansHospitalist
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA003172897Medicaid