=====================================================
General NPI Number Information
=====================================================
NPI Number | 1467643965
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | LARA V MARCUSE M.D.
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/08/2007
-----------------------------------------------------
Last Update Date | 08/13/2008
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 403 E 34TH ST 4TH FL
-----------------------------------------------------
City | NEW YORK
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 10016-4972
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 212-263-8871
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 18 E 41ST ST SUITE 1206
-----------------------------------------------------
City | NEW YORK
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 10017-6222
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 212-725-8511
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 2084N0400X
-----------------------------------------------------
Taxonomy Name | Neurology Physician
-----------------------------------------------------
License Number | 238985
-----------------------------------------------------
License Number State | NY
-----------------------------------------------------