Healthcare Provider Details

I. General information

NPI: 1033679584
Provider Name (Legal Business Name): LARISSA ASSAM MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/21/2019
Last Update Date: 08/20/2026
Certification Date: 08/20/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

158 AMITY RD # 280
NEW HAVEN CT
06515-1405
US

IV. Provider business mailing address

PO BOX 745254
ATLANTA GA
30374-5254
US

V. Phone/Fax

Practice location:
  • Phone: 203-404-3463
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberD0098982
License Number StateMD
# 2
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number80179
License Number StateCT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: