Healthcare Provider Details

I. General information

NPI: 1609921204
Provider Name (Legal Business Name): BRENT RAYMOND LARSON MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/24/2007
Last Update Date: 11/17/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1393 SANTA RITA RD SUITE F
PLEASANTON CA
94566-5665
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: 925-462-2335
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:
Title or Position:
Credential:
Phone: