Healthcare Provider Details

I. General information

NPI: 1306941794
Provider Name (Legal Business Name): MARIAM LARI M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/13/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

UMASS MEMORIAL CHILDREN'S MED. CTR. 55 LAKE AVENUE NORTH
WORCESTER MA
01655
US

IV. Provider business mailing address

376 COBURN AVE
WORCESTER MA
01604-1221
US

V. Phone/Fax

Practice location:
  • Phone: 508-856-3590
  • Fax:
Mailing address:
  • Phone: 508-856-3590
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number230214
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: