MEDICARE: DR. MICHAEL THEODORE LARDON M.D.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	2084P0800X	Psychiatry Physician	A48664	CA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1174630305
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. MICHAEL THEODORE LARDON M.D.

Provider Business Mailing Address
First Line	:	3750 CONVOY ST
Second Line	:	SUITE 318
City	:	SAN DIEGO
State	:	CA
Zip	:	92111-3738
Country	:	US
Telephone Number	:	858-292-2929
Fax Number	:	858-292-2909

Provider Business Practice Location Address
First Line	:	3750 CONVOY ST
Second Line	:	SUITE 318
City	:	SAN DIEGO
State	:	CA
Zip	:	92111-3738
Country	:	US
Telephone Number	:	858-292-2929
Fax Number	:	858-292-2909

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	08/24/2006
Last Update Date	:	07/08/2007

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