Basic Information
| Provider Information | |||||||||
| NPI: | 1780846113 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | LAROCHE | ||||||||
| FirstName: | MIRJA | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 68 S SERVICE RD | ||||||||
| Address2: | SUITE 350 | ||||||||
| City: | MELVILLE | ||||||||
| State: | NY | ||||||||
| PostalCode: | 11747 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5169453107 | ||||||||
| FaxNumber: | 5169453131 | ||||||||
| Practice Location | |||||||||
| Address1: | 3600 JOSEPH SIEWICK DR | ||||||||
| Address2: | ANESTHESIA DEPT | ||||||||
| City: | FAIRFAX | ||||||||
| State: | VA | ||||||||
| PostalCode: | 220331709 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7033913129 | ||||||||
| FaxNumber: | 7032959369 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/26/2008 | ||||||||
| LastUpdateDate: | 03/31/2016 | ||||||||
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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 | 207L00000X | 0101249195 | VA | Y | Allopathic & Osteopathic Physicians | Anesthesiology | 207L00000X | 2774281 | NY | N | Allopathic & Osteopathic Physicians | Anesthesiology |
ID Information
| ID | Type | State | Issuer | Description | 303887 | 01 | VA | KAISER | OTHER | 1780846113 | 05 | VA | MEDICAID | K142-0001 | 01 | DC | CARE FIRST | OTHER |