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NPI Code Detail

MEDICARE: DR. LARISSA DVORAK OD

MEDICARE: DR. LARISSA DVORAK OD
Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

# Taxonomy Code Taxonomy License Number License Number State
1152W00000XOptometristOPC3433FL

General Provider Information

NPI Number : 1053631135
Entity Type Code : Individual
Provider Name (Legal Business Name) : DR. LARISSA DVORAK OD
Provider Business Mailing Address
First Line : 6715 FERRI CIR
Second Line :
City : PORT ORANGE
State : FL
Zip : 32128-6031
Country : US
Telephone Number :
Fax Number :
Provider Business Practice Location Address
First Line : 1590 DUNLAWTON AVE
Second Line :
City : PORT ORANGE
State : FL
Zip : 32127-4752
Country : US
Telephone Number : 386-756-1900
Fax Number : 386-756-8133
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 06/10/2010
Last Update Date : 06/10/2010

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Directions to “ DR. LARISSA DVORAK OD” Practice Location

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