Provider Demographics
NPI:1295267458
Name:WERTALIK, LARISSA ANN (DO)
Entity type:Individual
Prefix:
First Name:LARISSA
Middle Name:ANN
Last Name:WERTALIK
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 1:9500 EUCLID AVE
Mailing Address - Street 2:
Mailing Address - City:CLEVELAND
Mailing Address - State:OH
Mailing Address - Zip Code:44195-0001
Mailing Address - Country:US
Mailing Address - Phone:216-444-5037
Mailing Address - Fax:
Practice Address - Street 1:1141 N ROAD ST STE M
Practice Address - Street 2:SENTARA PEDIATRIC PHYSICIANS
Practice Address - City:ELIZABETH CITY
Practice Address - State:NC
Practice Address - Zip Code:27909
Practice Address - Country:US
Practice Address - Phone:252-384-2590
Practice Address - Fax:252-384-2589
Is Sole Proprietor?:No
Enumeration Date:2017-03-28
Last Update Date:2024-08-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY305439208000000X
OH34.015369208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics