Basic Information
| Provider Information | |||||||||
| NPI: | 1295267458 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | WERTALIK | ||||||||
| FirstName: | LARISSA | ||||||||
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| Credential: | DO | ||||||||
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| Mailing Information | |||||||||
| Address1: | 9500 EUCLID AVE | ||||||||
| Address2: | |||||||||
| City: | CLEVELAND | ||||||||
| State: | OH | ||||||||
| PostalCode: | 441950001 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2164445037 | ||||||||
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| Practice Location | |||||||||
| Address1: | 47 NEW SCOTLAND AVE | ||||||||
| Address2: | DEPARTMENT OF PEDIATRICS | ||||||||
| City: | ALBANY | ||||||||
| State: | NY | ||||||||
| PostalCode: | 12208 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5182626248 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 03/28/2017 | ||||||||
| LastUpdateDate: | 02/04/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 09/10/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208000000X | 305439 | NY | N | Allopathic & Osteopathic Physicians | Pediatrics | 208000000X | 34.015369 | OH | Y | Allopathic & Osteopathic Physicians | Pediatrics |
No ID Information.