Healthcare Provider Details

I. General information

NPI: 1982634135
Provider Name (Legal Business Name): LARISSA M COLON-BENGOA MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/04/2006
Last Update Date: 04/01/2025
Certification Date: 04/01/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1901 S CONGRESS AVE STE 420
BOYNTON BEACH FL
33426-6588
US

IV. Provider business mailing address

20036 SE BRIDGEWATER DR
JUPITER FL
33458-1651
US

V. Phone/Fax

Practice location:
  • Phone: 561-364-1479
  • Fax:
Mailing address:
  • Phone: 561-676-8109
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207QH0002X
TaxonomyHospice and Palliative Medicine (Family Medicine) Physician
License NumberME87982
License Number StateFL
# 2
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberME87982
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: