Provider Demographics
NPI:1255376711
Name:ZAULYANOV SCANLAN, LARISSA (MD)
Entity type:Individual
Prefix:
First Name:LARISSA
Middle Name:
Last Name:ZAULYANOV SCANLAN
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 1:13550 JOG ROAD
Mailing Address - Street 2:S. D201
Mailing Address - City:DELRAY BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:33446-3809
Mailing Address - Country:US
Mailing Address - Phone:561-637-2516
Mailing Address - Fax:561-637-4657
Practice Address - Street 1:13550 JOG ROAD
Practice Address - Street 2:S. D201
Practice Address - City:DELRAY BEACH
Practice Address - State:FL
Practice Address - Zip Code:33446-3809
Practice Address - Country:US
Practice Address - Phone:561-637-2516
Practice Address - Fax:561-637-4657
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-18
Last Update Date:2015-06-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME95300207ND0101X, 207ND0101X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207ND0101XAllopathic & Osteopathic PhysiciansDermatologyMOHS-Micrographic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLME95300OtherLICENSE