Healthcare Provider Details

I. General information

NPI: 1144230905
Provider Name (Legal Business Name): LARISA RAVITSKIY MD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/08/2006
Last Update Date: 08/28/2026
Certification Date: 08/28/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6451 MERRITT BLVD STE D
DAPHNE AL
36526-4827
US

IV. Provider business mailing address

6451 MERRITT BLVD STE D
DAPHNE AL
36526-4827
US

V. Phone/Fax

Practice location:
  • Phone: 251-220-0080
  • Fax:
Mailing address:
  • Phone: 251-220-0080
  • Fax: 251-220-0081

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207ND0101X
TaxonomyMOHS-Micrographic Surgery Physician
License Number50664
License Number StateAL
# 2
Primary TaxonomyY
Taxonomy Code207N00000X
TaxonomyDermatology Physician
License Number50664
License Number StateAL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: