MEDICARE: LARISA MALISOVA DO

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	208D00000X	General Practice Physician	234484	NY

General Provider Information

NPI Number	:	1861448896
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	LARISA MALISOVA DO

Provider Business Mailing Address
First Line	:	1270 E 19TH ST
Second Line	:	APT. 6 M
City	:	BROOKLYN
State	:	NY
Zip	:	11230-5457
Country	:	US
Telephone Number	:	718-338-0164
Fax Number	:

Provider Business Practice Location Address
First Line	:	420 LYNDALE AVE
Second Line	:
City	:	STATEN ISLAND
State	:	NY
Zip	:	10312-6131
Country	:	US
Telephone Number	:	718-967-5630
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	05/25/2006
Last Update Date	:	05/28/2010

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