Basic Information
| Provider Information | |||||||||
| NPI: | 1841325339 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | KLEYMENOVA | ||||||||
| FirstName: | LARISA | ||||||||
| MiddleName: | V. | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 158 W 27TH ST | ||||||||
| Address2: | 11TH FLOOR SOUTH | ||||||||
| City: | NEW YORK | ||||||||
| State: | NY | ||||||||
| PostalCode: | 100016216 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2125632627 | ||||||||
| FaxNumber: | 2125630605 | ||||||||
| Practice Location | |||||||||
| Address1: | 5115 BEACH CHANNEL DR | ||||||||
| Address2: | |||||||||
| City: | FAR ROCKAWAY | ||||||||
| State: | NY | ||||||||
| PostalCode: | 116911042 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2125632627 | ||||||||
| FaxNumber: | 2125630605 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/23/2007 | ||||||||
| LastUpdateDate: | 07/09/2007 | ||||||||
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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 | 207Q00000X | 230116 | NY | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 02498626 | 05 | NY | MEDICAID |