Healthcare Provider Details

I. General information

NPI: 1932661188
Provider Name (Legal Business Name): LARISSA RAE BRANDENBURG DO
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/04/2019
Last Update Date: 08/21/2026
Certification Date: 08/21/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4389 BEAUFORT RD
HAVELOCK NC
28532
US

IV. Provider business mailing address

ATTN: CREDENTIALS OFFICE 4389 BEAUFORT RD
HAVELOCK NC
28532
US

V. Phone/Fax

Practice location:
  • Phone: 252-466-4079
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code171000000X
TaxonomyMilitary Health Care Provider
License Number0102206224
License Number StateVA
# 2
Primary TaxonomyY
Taxonomy Code2083A0100X
TaxonomyAerospace Medicine Physician
License Number0102206224
License Number StateVA
# 3
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
License NumberOS18242
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: