1144219023 NPI number — DR. LARISA I ALLAKHVERDOVA MD

Table of content: DR. LARISA I ALLAKHVERDOVA MD (NPI 1144219023)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1144219023 NPI number — DR. LARISA I ALLAKHVERDOVA MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
ALLAKHVERDOVA
Provider First Name:
LARISA
Provider Middle Name:
I
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
MD
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1144219023
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
03/27/2018
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
200 CORPORATE BLVD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
LAFAYETTE
Provider Business Mailing Address State Name:
LA
Provider Business Mailing Address Postal Code:
70508-3870
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
800-893-9698
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1225 E COOLSPRING AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
MICHIGAN CITY
Provider Business Practice Location Address State Name:
IN
Provider Business Practice Location Address Postal Code:
46360-6312
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
219-873-2919
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
10/13/2005

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 207P00000X , with the licence number:  228819 , registered in the state of NY ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207P00000X , with the licence number: 01057834A , registered in the state of IN ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: P01186413 . This is a "MEDICARE RAILROAD" identifier , issued by the state of ( KY ) . This identifiers is of the category "OTHER".
  • Identifier: 02844177 , issued by the state of ( NY ) . This identifiers is of the category "MEDICAID".
  • Identifier: 200805060 , issued by the state of ( IN ) . This identifiers is of the category "MEDICAID".
  • Identifier: M47140293 . This is a "MEDICARE" identifier , issued by the state of ( IN ) . This identifiers is of the category "OTHER".




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