Individual
LARISSA M DIMITROV
Active
Sole proprietor
No
Provider details
NPI number
Gender
F
Credential
MD
Contact information
Practice address
4166 LEXINGTON AVE N, SHOREVIEW, MN 55126-6106
(651) 483-5461
Mailing address
2925 CHICAGO AVE, MINNEAPOLIS, MN 55407-1321
(612) 262-9000
Taxonomy
Speciality
Code
Description
License number
State
207Q00000X
Family Medicine Physician
Primary
72958
MN
207QG0300X
Geriatric Medicine (Family Medicine) Physician
72958
MN
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
01062576A
LICENSE
IN
Enumeration date
12/17/2007
Last updated
09/26/2023
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