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General NPI Number Information
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NPI Number | 1578610739
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Entity Type | Individual
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Provider Name | JOHN MARK LARSEN M.D.
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Gender | Male
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Dates
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Enumeration Date | 01/03/2007
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Last Update Date | 07/08/2007
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Provider Practice Location Address
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Address Line | 1700 LOMBARD ST SUITE 110
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City | OXNARD
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State | CA
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Zip | 93030-8211
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Country | US
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Telephone | 805-988-6510
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Fax | 805-988-6550
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Provider Business Mailing Address
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Address Line | 1700 LOMBARD ST SUITE 110
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City | OXNARD
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State | CA
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Zip | 93030-8211
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Country | US
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Telephone | 805-988-6510
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Fax | 805-988-6550
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 204C00000X
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Taxonomy Name | Sports Medicine (Neuromusculoskeletal Medicine) Physician
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License Number | G61959
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License Number State | CA
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