Provider Demographics
NPI:1053361550
Name:KLOTS, LARISA (DO)
Entity type:Individual
Prefix:DR
First Name:LARISA
Middle Name:
Last Name:KLOTS
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11 BUFFALO RUN
Mailing Address - Street 2:
Mailing Address - City:EAST BRUNSWICK
Mailing Address - State:NJ
Mailing Address - Zip Code:08816-4078
Mailing Address - Country:US
Mailing Address - Phone:732-254-1114
Mailing Address - Fax:732-254-2247
Practice Address - Street 1:B3 BRIER HILL CT
Practice Address - Street 2:
Practice Address - City:EAST BRUNSWICK
Practice Address - State:NJ
Practice Address - Zip Code:08816-3330
Practice Address - Country:US
Practice Address - Phone:732-254-1114
Practice Address - Fax:732-254-2247
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-12
Last Update Date:2013-09-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJMB71358207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJG90998Medicare UPIN
NJ044785Medicare ID - Type Unspecified