Healthcare Provider Details

I. General information

NPI: 1134362718
Provider Name (Legal Business Name): DAVID WAYNE LARISCY MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/13/2009
Last Update Date: 03/13/2023
Certification Date: 03/13/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1058 BERMUDA RUN
STATESBORO GA
30458-0858
US

IV. Provider business mailing address

103 WINDY HILL CT
STATESBORO GA
30458-9139
US

V. Phone/Fax

Practice location:
  • Phone: 912-243-9274
  • Fax: 912-341-6513
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207UN0901X
TaxonomyNuclear Cardiology Physician
License Number074285
License Number StateGA
# 2
Primary TaxonomyN
Taxonomy Code208M00000X
TaxonomyHospitalist Physician
License Number56424
License Number StateKY
# 3
Primary TaxonomyY
Taxonomy Code207RC0000X
TaxonomyCardiovascular Disease Physician
License Number074285
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: