Healthcare Provider Details

I. General information

NPI: 1386629285
Provider Name (Legal Business Name): LARISSA S OSTROVSKAIA M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/13/2005
Last Update Date: 09/06/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

30 PROSPECT AVE
HACKENSACK NJ
07601-1914
US

IV. Provider business mailing address

130 KINDERKAMACK RD SUITE 200
RIVER EDGE NJ
07661
US

V. Phone/Fax

Practice location:
  • Phone: 201-996-2200
  • Fax: 201-489-2812
Mailing address:
  • Phone: 201-488-2660
  • Fax: 201-489-2812

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License Number25MA07088900
License Number StateNJ

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
Identifier8345406
Identifier TypeMEDICAID
Identifier StateNJ
Identifier Issuer

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: