Healthcare Provider Details

I. General information

NPI: 1083239727
Provider Name (Legal Business Name): LARISSA LARSEN DERMATOLOGY INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/09/2020
Last Update Date: 11/27/2023
Certification Date: 06/09/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2460 N PONDEROSA DR STE A117
CAMARILLO CA
93010-2468
US

IV. Provider business mailing address

2460 N PONDEROSA DR STE A117
CAMARILLO CA
93010-2468
US

V. Phone/Fax

Practice location:
  • Phone: 805-430-0002
  • Fax: 805-389-1245
Mailing address:
  • Phone: 805-430-0002
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code261QM2500X
TaxonomyMedical Specialty Clinic/Center
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code207N00000X
TaxonomyDermatology Physician
License Number
License Number State

VIII. Authorized Official

Name: LARISSA NADIA LARSEN
Title or Position: OWNER
Credential: MD
Phone: 805-807-2367