Provider Demographics
NPI:1497774210
Name:RODRIGUEZ, LARISSA V (MD)
Entity type:Individual
Prefix:DR
First Name:LARISSA
Middle Name:V
Last Name:RODRIGUEZ
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:525 E 68TH ST # 94
Mailing Address - Street 2:
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10065-4870
Mailing Address - Country:US
Mailing Address - Phone:646-962-7170
Mailing Address - Fax:
Practice Address - Street 1:525 E 68TH ST # 94
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10065-4870
Practice Address - Country:US
Practice Address - Phone:646-962-7170
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-19
Last Update Date:2023-07-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA54911208800000X, 2088F0040X
NY315776208800000X, 2088F0040X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2088F0040XAllopathic & Osteopathic PhysiciansUrologyUrogynecology and Reconstructive Pelvic Surgery
No208800000XAllopathic & Osteopathic PhysiciansUrology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CALR1067Medicaid
CAH24420Medicare UPIN
CAWA54911AMedicare PIN