Healthcare Provider Details

I. General information

NPI: 1730473885
Provider Name (Legal Business Name): KIMBERLY ANNE LARSON MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: KIMBERLY BOUCHARD

II. Dates (important events)

Enumeration Date: 06/07/2011
Last Update Date: 12/04/2025
Certification Date: 12/04/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

747 52ND ST
OAKLAND CA
94609-1809
US

IV. Provider business mailing address

1601 YGNACIO VALLEY RD
WALNUT CREEK CA
94598-3122
US

V. Phone/Fax

Practice location:
  • Phone: 510-428-3276
  • Fax:
Mailing address:
  • Phone: 925-947-5350
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberA148236
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code2080N0001X
TaxonomyNeonatal-Perinatal Medicine Physician
License NumberA148236
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: