Healthcare Provider Details

I. General information

NPI: 1063409985
Provider Name (Legal Business Name): TIMOTHY LAROSA MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/05/2005
Last Update Date: 02/11/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1 ANNA MARSH LANE
BRATTLEBORO VT
05302-0101
US

IV. Provider business mailing address

PO BOX 1906
MANCHESTER CENTER VT
05255-1906
US

V. Phone/Fax

Practice location:
  • Phone: 802-258-3707
  • Fax: 802-258-3788
Mailing address:
  • Phone: 802-375-9759
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number042-0009710
License Number StateVT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: