Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 204C00000X | Sports Medicine Doctor | G61959 | CA |
NPI | 1578610739 |
---|---|
Provider Name | Dr. John Mark Larsen |
First Address | Oxnard, CA 93030-8211 |
Second Address | Oxnard, CA 93030-8211 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 03/01/2007 |
Last Update Date | 08/07/2007 |