Provider Demographics
NPI:1952534547
Name:GUERRERO, LARISSA ANTONIA (MD)
Entity Type:Individual
Prefix:
First Name:LARISSA
Middle Name:ANTONIA
Last Name:GUERRERO
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:LARISSA
Other - Middle Name:ANTONIA
Other - Last Name:SUBERO GUERRERO
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:1071 S SUN DR
Mailing Address - Street 2:SUITE 1043
Mailing Address - City:LAKE MARY
Mailing Address - State:FL
Mailing Address - Zip Code:32746-2405
Mailing Address - Country:US
Mailing Address - Phone:407-333-1616
Mailing Address - Fax:407-333-1617
Practice Address - Street 1:1071 S SUN DR
Practice Address - Street 2:SUITE 1043
Practice Address - City:LAKE MARY
Practice Address - State:FL
Practice Address - Zip Code:32746-2405
Practice Address - Country:US
Practice Address - Phone:407-333-1616
Practice Address - Fax:407-333-1617
Is Sole Proprietor?:No
Enumeration Date:2009-08-28
Last Update Date:2015-06-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME 121834207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC342677Medicaid
SC342677Medicaid
SCAA85621849Medicare PIN