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NPI Code Detail

MEDICARE: LARESA RIDGE M.D.

MEDICARE: LARESA RIDGE M.D.
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
1207Q00000XFamily Medicine PhysicianL7535TX

Other Identifiers

# Provider Identifier Provider Identifier Type Provider Identifier State Provider Identifier Issuer
18P2795OTHERTXBCBS
2MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number : 1831120310
Entity Type Code : Individual
Provider Name (Legal Business Name) : LARESA RIDGE M.D.
Provider Business Mailing Address
First Line : 17330 LASSEN FOREST LN
Second Line :
City : HUMBLE
State : TX
Zip : 77346-1550
Country : US
Telephone Number : 281-788-2615
Fax Number :
Provider Business Practice Location Address
First Line : 9105 N WAYSIDE DR
Second Line :
City : HOUSTON
State : TX
Zip : 77028-1030
Country : US
Telephone Number : 214-276-8665
Fax Number :
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 07/05/2006
Last Update Date : 11/11/2019

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Directions to “ LARESA RIDGE M.D.” Practice Location

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