MEDICARE: DR. LARRY MARK WEISENTHAL MD., PHD.

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	207RH0003X	Hematology & Oncology Physician	66724	CA

Medicare Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	G41204	OTHER	CA	MEDICARE PROVIDER #

General Provider Information

NPI Number	:	1568497519
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. LARRY MARK WEISENTHAL MD., PHD.

Provider Business Mailing Address
First Line	:	16512 BURKE LANE
Second Line	:
City	:	HUNTINGTON BEACH
State	:	CA
Zip	:	92647-4538
Country	:	US
Telephone Number	:	714-596-2100
Fax Number	:	714-596-2110

Provider Business Practice Location Address
First Line	:	16512 BURKE LANE
Second Line	:
City	:	HUNTINGTON BEACH
State	:	CA
Zip	:	92647-4538
Country	:	US
Telephone Number	:	714-596-2100
Fax Number	:	714-596-2110

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

Provider Enumeration Date	:	07/11/2006
Last Update Date	:	05/17/2012

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