Healthcare Provider Details

I. General information

NPI: 1164545737
Provider Name (Legal Business Name): BRENT R LARSON, M.D., INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/09/2007
Last Update Date: 11/17/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1393 SANTA RITA RD STE F
PLEASANTON CA
94566-5667
US

IV. Provider business mailing address

210 N TUSTIN AVE
SANTA ANA CA
92705-3807
US

V. Phone/Fax

Practice location:
  • Phone: 925-462-2334
  • Fax:
Mailing address:
  • Phone: 714-347-1012
  • Fax: 714-647-1245

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207L00000X
TaxonomyAnesthesiology Physician
License NumberA63652
License Number StateCA

VIII. Authorized Official

Name: DR. BRENT RAYMOND LARSON
Title or Position: PRESIDENT
Credential: M.D.
Phone: 800-883-7243