Provider Demographics
NPI:1982634135
Name:COLON-BENGOA, LARISSA M (MD)
Entity type:Individual
Prefix:
First Name:LARISSA
Middle Name:M
Last Name:COLON-BENGOA
Suffix:
Gender:
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:20036 SE BRIDGEWATER DR
Mailing Address - Street 2:
Mailing Address - City:JUPITER
Mailing Address - State:FL
Mailing Address - Zip Code:33458-1651
Mailing Address - Country:US
Mailing Address - Phone:561-676-8109
Mailing Address - Fax:
Practice Address - Street 1:1901 S CONGRESS AVE STE 420
Practice Address - Street 2:
Practice Address - City:BOYNTON BEACH
Practice Address - State:FL
Practice Address - Zip Code:33426-6588
Practice Address - Country:US
Practice Address - Phone:561-364-1479
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-04
Last Update Date:2025-04-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME87982207QH0002X, 207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No207QH0002XAllopathic & Osteopathic PhysiciansFamily MedicineHospice and Palliative Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLI15352Medicare UPIN
FLU3056ZMedicare ID - Type Unspecified