Provider Demographics
NPI:1063414639
Name:VENEZIA, LARISA V (DO)
Entity type:Individual
Prefix:MS
First Name:LARISA
Middle Name:V
Last Name:VENEZIA
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:46 ROUTE 25A
Mailing Address - Street 2:SUITE 6
Mailing Address - City:SETAUKET
Mailing Address - State:NY
Mailing Address - Zip Code:11733-2820
Mailing Address - Country:US
Mailing Address - Phone:631-689-1444
Mailing Address - Fax:631-689-1448
Practice Address - Street 1:46 ROUTE 25A
Practice Address - Street 2:SUITE 6
Practice Address - City:EAST SETAUKET
Practice Address - State:NY
Practice Address - Zip Code:11733
Practice Address - Country:US
Practice Address - Phone:631-689-1444
Practice Address - Fax:631-689-1448
Is Sole Proprietor?:Yes
Enumeration Date:2005-08-12
Last Update Date:2010-12-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY2307881207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY0606P2OtherMEDICARE P-TAN
NY0606P2Medicare ID - Type Unspecified
I03751Medicare UPIN