Provider Demographics
NPI:1285933838
Name:LAROSE, LISA DANG (MD)
Entity type:Individual
Prefix:DR
First Name:LISA
Middle Name:DANG
Last Name:LAROSE
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:MALCOLM GROW MEDICAL CLINICS AND SURGERY CENTER
Mailing Address - Street 2:1060 W. PERIMETER RD
Mailing Address - City:JB ANDREWS
Mailing Address - State:MD
Mailing Address - Zip Code:20762
Mailing Address - Country:US
Mailing Address - Phone:240-612-2020
Mailing Address - Fax:240-612-3880
Practice Address - Street 1:1060 W PERIMETER RD
Practice Address - Street 2:
Practice Address - City:JB ANDREWS
Practice Address - State:MD
Practice Address - Zip Code:20762-6602
Practice Address - Country:US
Practice Address - Phone:240-612-2020
Practice Address - Fax:240-612-3880
Is Sole Proprietor?:Yes
Enumeration Date:2011-03-22
Last Update Date:2023-08-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA01012543042083P0500X, 208D00000X, 2085R0202X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic RadiologyGroup - Single Specialty
No2083P0500XAllopathic & Osteopathic PhysiciansPreventive MedicinePreventive Medicine/Occupational Environmental Medicine
No208D00000XAllopathic & Osteopathic PhysiciansGeneral PracticeGroup - Single Specialty
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training ProgramGroup - Single Specialty