Provider Demographics
NPI:1184899049
Name:PAVONE, LARISSA RAE (MD)
Entity type:Individual
Prefix:DR
First Name:LARISSA
Middle Name:RAE
Last Name:PAVONE
Suffix:
Gender:F
Credentials:MD
Other - Prefix:DR
Other - First Name:LARISSA
Other - Middle Name:RAE
Other - Last Name:RAMAIZEL
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:26W171 ROOSEVELT ROAD
Mailing Address - Street 2:MARIANJOY REHABILITATION HOSPITAL
Mailing Address - City:WHEATON
Mailing Address - State:IL
Mailing Address - Zip Code:60187
Mailing Address - Country:US
Mailing Address - Phone:630-909-7337
Mailing Address - Fax:630-909-7039
Practice Address - Street 1:26W171 ROOSEVELT ROAD
Practice Address - Street 2:MARIANJOY REHABILITATION HOSPITAL
Practice Address - City:WHEATON
Practice Address - State:IL
Practice Address - Zip Code:60187
Practice Address - Country:US
Practice Address - Phone:630-909-7337
Practice Address - Fax:630-909-7039
Is Sole Proprietor?:No
Enumeration Date:2008-04-22
Last Update Date:2018-02-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL125051399208100000X
IL036.125665208100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & Rehabilitation