MEDICARE: DR. FABIENNE LARAQUE MD

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
1	207R00000X	Internal Medicine Physician	2034311	NY

General Provider Information

NPI Number	:	1144274762
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. FABIENNE LARAQUE MD

Provider Business Mailing Address
First Line	:	4209 28TH ST
Second Line	:	NYCDOHMH DIVISION OF DISEASE CONTROL-BCD WS 5-71
City	:	LONG ISLAND CITY
State	:	NY
Zip	:	11101-4130
Country	:	US
Telephone Number	:	347-396-7415
Fax Number	:

Provider Business Practice Location Address
First Line	:	4209 28TH ST
Second Line	:	NYCDOHMH DIVISION OF DISEASE CONTROL-BCD WS 5-71
City	:	LONG ISLAND CITY
State	:	NY
Zip	:	11101-4130
Country	:	US
Telephone Number	:	347-396-7415
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	05/19/2006
Last Update Date	:	09/04/2015

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