Healthcare Provider Details

I. General information

NPI: 1790766160
Provider Name (Legal Business Name): STEVEN EDWIN LARSON MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/10/2005
Last Update Date: 12/29/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7117 BROCKTON AVE
RIVERSIDE CA
92506-2615
US

IV. Provider business mailing address

3660 ARLINGTON AVE
RIVERSIDE CA
92506-3912
US

V. Phone/Fax

Practice location:
  • Phone: 951-782-3618
  • Fax: 951-784-3272
Mailing address:
  • Phone: 951-782-5110
  • Fax: 951-274-0403

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License NumberG41825
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code207RI0200X
TaxonomyInfectious Disease Physician
License NumberG41825
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: