Healthcare Provider Details

I. General information

NPI: 1205999752
Provider Name (Legal Business Name): LARISSA LUCAS
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/18/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

237 HAMPSHIRE ST
CAMBRIDGE MA
02139-1389
US

IV. Provider business mailing address

237 HAMPSHIRE ST
CAMBRIDGE MA
02139-1389
US

V. Phone/Fax

Practice location:
  • Phone: 617-575-5570
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number208147
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: