Provider Demographics
NPI:1851321855
Name:KHISHCHENKO, LARISA (MD)
Entity type:Individual
Prefix:DR
First Name:LARISA
Middle Name:
Last Name:KHISHCHENKO
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 1:485 TITUS AVE
Mailing Address - Street 2:STE H
Mailing Address - City:ROCHESTER
Mailing Address - State:NY
Mailing Address - Zip Code:14617-3535
Mailing Address - Country:US
Mailing Address - Phone:585-338-2530
Mailing Address - Fax:585-338-7304
Practice Address - Street 1:485 TITUS AVE
Practice Address - Street 2:STE H
Practice Address - City:ROCHESTER
Practice Address - State:NY
Practice Address - Zip Code:14617-3535
Practice Address - Country:US
Practice Address - Phone:585-338-2530
Practice Address - Fax:585-338-7304
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-04
Last Update Date:2021-05-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY180528207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY102621BJOtherPREFERRED CARE
NY01584647Medicaid
NYP010180528OtherBLUE CHOICE
NYP050180528OtherBC/BS