Healthcare Provider Details

I. General information

NPI: 1326189671
Provider Name (Legal Business Name): LARRY I. EMDUR, D.O., PHD.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/09/2007
Last Update Date: 08/06/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5555 RESERVOIR DR 201
SAN DIEGO CA
92120-5134
US

IV. Provider business mailing address

5173 WARING RD SUITE 125
SAN DIEGO CA
92120-2705
US

V. Phone/Fax

Practice location:
  • Phone: 619-286-8803
  • Fax: 619-286-2344
Mailing address:
  • Phone: 619-286-8803
  • Fax: 619-286-2344

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code174400000X
TaxonomySpecialist
License Number20A4940
License Number StateCA

VIII. Authorized Official

Name: DR. LARRY I EMDUR
Title or Position: PRESIDENT,OWNER
Credential: D.O.
Phone: 619-286-8803