Healthcare Provider Details

I. General information

NPI: 1588849756
Provider Name (Legal Business Name): LARISSA JANETTE FORDYCE-RICHARDS M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: LARISSA JANETTE LAKATOS M.D

II. Dates (important events)

Enumeration Date: 01/07/2008
Last Update Date: 12/01/2020
Certification Date: 12/01/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1300 FORT PIERPONT DR STE 101
MORGANTOWN WV
26508-1314
US

IV. Provider business mailing address

1300 FORT PIERPONT DR STE 101
MORGANTOWN WV
26508-1314
US

V. Phone/Fax

Practice location:
  • Phone: 304-241-7150
  • Fax: 304-599-8917
Mailing address:
  • Phone: 304-241-7150
  • Fax: 304-599-8917

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number23519
License Number StateWV
# 2
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberMD439510
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: