Provider Demographics
NPI:1528117108
Name:POTAP, LARISA (MD)
Entity type:Individual
Prefix:DR
First Name:LARISA
Middle Name:
Last Name:POTAP
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2299 POST STREET
Mailing Address - Street 2:SUITE 313
Mailing Address - City:SAN FRANCISCO
Mailing Address - State:CA
Mailing Address - Zip Code:94115
Mailing Address - Country:US
Mailing Address - Phone:415-928-0134
Mailing Address - Fax:415-928-1832
Practice Address - Street 1:2299 POST STREET
Practice Address - Street 2:SUITE 313
Practice Address - City:SAN FRANCISCO
Practice Address - State:CA
Practice Address - Zip Code:94115
Practice Address - Country:US
Practice Address - Phone:415-928-0134
Practice Address - Fax:415-928-1832
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-10
Last Update Date:2008-09-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA50047207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A500470Medicaid
CA00A500470Medicaid
CAOOA500470Medicare ID - Type Unspecified