Healthcare Provider Details

I. General information

NPI: 1649379181
Provider Name (Legal Business Name): LARISA KLOTS DO INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/21/2006
Last Update Date: 09/06/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

B3 BRIER HILL CT
E BRUNSWICK NJ
08816-3330
US

IV. Provider business mailing address

11 BUFFALO RUN
E BRUNSWICK NJ
08816-4078
US

V. Phone/Fax

Practice location:
  • Phone: 732-254-1114
  • Fax: 732-254-2247
Mailing address:
  • Phone: 732-254-1114
  • Fax: 732-254-2247

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberMB71358
License Number StateNJ

VIII. Authorized Official

Name: DR. LARISA KLOTS
Title or Position: PRESIDENT
Credential: DO
Phone: 732-257-8442