Provider Demographics
NPI:1679049076
Name:LARSON MEDICAL GROUP, INC
Entity type:Organization
Organization Name:LARSON MEDICAL GROUP, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:M
Authorized Official - Last Name:LARSON
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:858-367-3401
Mailing Address - Street 1:1042 N EL CAMINO REAL STE B380
Mailing Address - Street 2:
Mailing Address - City:ENCINITAS
Mailing Address - State:CA
Mailing Address - Zip Code:92024-1322
Mailing Address - Country:US
Mailing Address - Phone:858-367-3401
Mailing Address - Fax:888-734-5568
Practice Address - Street 1:1442 CAMINO DEL MAR STE 212
Practice Address - Street 2:
Practice Address - City:DEL MAR
Practice Address - State:CA
Practice Address - Zip Code:92014-2550
Practice Address - Country:US
Practice Address - Phone:760-634-1704
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-10-23
Last Update Date:2018-10-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty