Provider Demographics
NPI:1144678517
Name:ROLIM, LARISSA (DPM, MS)
Entity type:Individual
Prefix:
First Name:LARISSA
Middle Name:
Last Name:ROLIM
Suffix:
Gender:F
Credentials:DPM, MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1440 N MACARTHUR BLVD STE 101
Mailing Address - Street 2:
Mailing Address - City:IRVING
Mailing Address - State:TX
Mailing Address - Zip Code:75061-4401
Mailing Address - Country:US
Mailing Address - Phone:469-777-4078
Mailing Address - Fax:469-777-4051
Practice Address - Street 1:1440 N MACARTHUR BLVD STE 101
Practice Address - Street 2:
Practice Address - City:IRVING
Practice Address - State:TX
Practice Address - Zip Code:75061-4401
Practice Address - Country:US
Practice Address - Phone:469-777-4078
Practice Address - Fax:469-777-4051
Is Sole Proprietor?:No
Enumeration Date:2016-05-26
Last Update Date:2020-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX2199213ES0103X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle Surgery