Provider Demographics
NPI:1205947074
Name:LARSEN, METTE (DO)
Entity type:Individual
Prefix:
First Name:METTE
Middle Name:
Last Name:LARSEN
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:300 E MAIN ST
Mailing Address - Street 2:
Mailing Address - City:CENTERPORT
Mailing Address - State:NY
Mailing Address - Zip Code:11721-1435
Mailing Address - Country:US
Mailing Address - Phone:631-424-2342
Mailing Address - Fax:877-991-7656
Practice Address - Street 1:2248 ROANOKE AVE
Practice Address - Street 2:
Practice Address - City:RIVERHEAD
Practice Address - State:NY
Practice Address - Zip Code:11901-1822
Practice Address - Country:US
Practice Address - Phone:917-572-9745
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-31
Last Update Date:2016-12-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY200286207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01623418Medicaid
NY07454QMedicare PIN
NYF14137Medicare UPIN
NY01623418Medicaid