Healthcare Provider Details

I. General information

NPI: 1285933838
Provider Name (Legal Business Name): LISA DANG LAROSE M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/22/2011
Last Update Date: 08/04/2023
Certification Date: 08/04/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1060 W PERIMETER RD
JB ANDREWS MD
20762-6602
US

IV. Provider business mailing address

MALCOLM GROW MEDICAL CLINICS AND SURGERY CENTER 1060 W. PERIMETER RD
JB ANDREWS MD
20762
US

V. Phone/Fax

Practice location:
  • Phone: 240-612-2020
  • Fax: 240-612-3880
Mailing address:
  • Phone: 240-612-2020
  • Fax: 240-612-3880

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code2083P0500X
TaxonomyPreventive Medicine/Occupational Environmental Medicine Physician
License Number0101254304
License Number StateVA
# 3
Primary TaxonomyY
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License Number0101254304
License Number StateVA
# 4
Primary TaxonomyN
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
License Number0101254304
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: