Healthcare Provider Details

I. General information

NPI: 1609825736
Provider Name (Legal Business Name): LARISA KHESINA M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/08/2006
Last Update Date: 12/17/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

15034 UNION TPKE
FLUSHING NY
11367-3928
US

IV. Provider business mailing address

15034 UNION TPKE
FLUSHING NY
11367-3928
US

V. Phone/Fax

Practice location:
  • Phone: 718-380-0011
  • Fax: 718-820-0841
Mailing address:
  • Phone: 718-380-0011
  • Fax: 718-820-0841

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number203378
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: