Healthcare Provider Details

I. General information

NPI: 1578610739
Provider Name (Legal Business Name): JOHN MARK LARSEN M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/03/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1700 LOMBARD ST SUITE 110
OXNARD CA
93030-8211
US

IV. Provider business mailing address

1700 LOMBARD ST SUITE 110
OXNARD CA
93030-8211
US

V. Phone/Fax

Practice location:
  • Phone: 805-988-6510
  • Fax: 805-988-6550
Mailing address:
  • Phone: 805-988-6510
  • Fax: 805-988-6550

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code204C00000X
TaxonomySports Medicine (Neuromusculoskeletal Medicine) Physician
License NumberG61959
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: