Basic Information
| Provider Information | |||||||||
| NPI: | 1144219023 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | ALLAKHVERDOVA | ||||||||
| FirstName: | LARISA | ||||||||
| MiddleName: | I | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 200 CORPORATE BLVD | ||||||||
| Address2: | |||||||||
| City: | LAFAYETTE | ||||||||
| State: | LA | ||||||||
| PostalCode: | 705083870 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8008939698 | ||||||||
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| Practice Location | |||||||||
| Address1: | 1225 E COOLSPRING AVE | ||||||||
| Address2: | |||||||||
| City: | MICHIGAN CITY | ||||||||
| State: | IN | ||||||||
| PostalCode: | 463606312 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2198732919 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 10/13/2005 | ||||||||
| LastUpdateDate: | 03/27/2018 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207P00000X | 228819 | NY | N | Allopathic & Osteopathic Physicians | Emergency Medicine | 207P00000X | 01057834A | IN | Y | Allopathic & Osteopathic Physicians | Emergency Medicine |
ID Information
| ID | Type | State | Issuer | Description | P01186413 | 01 | KY | MEDICARE RAILROAD | OTHER | 02844177 | 05 | NY | MEDICAID | 200805060 | 05 | IN | MEDICAID | M47140293 | 01 | IN | MEDICARE | OTHER |