Provider Demographics
NPI:1588849756
Name:FORDYCE-RICHARDS, LARISSA JANETTE (MD)
Entity type:Individual
Prefix:DR
First Name:LARISSA
Middle Name:JANETTE
Last Name:FORDYCE-RICHARDS
Suffix:
Gender:F
Credentials:MD
Other - Prefix:DR
Other - First Name:LARISSA
Other - Middle Name:JANETTE
Other - Last Name:LAKATOS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:1300 FORT PIERPONT DR STE 101
Mailing Address - Street 2:
Mailing Address - City:MORGANTOWN
Mailing Address - State:WV
Mailing Address - Zip Code:26508-1314
Mailing Address - Country:US
Mailing Address - Phone:304-241-7150
Mailing Address - Fax:304-599-8917
Practice Address - Street 1:1300 FORT PIERPONT DR STE 101
Practice Address - Street 2:
Practice Address - City:MORGANTOWN
Practice Address - State:WV
Practice Address - Zip Code:26508-1314
Practice Address - Country:US
Practice Address - Phone:304-241-7150
Practice Address - Fax:304-599-8917
Is Sole Proprietor?:No
Enumeration Date:2008-01-07
Last Update Date:2020-12-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV23519207Q00000X
PAMD439510207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine