MEDICARE: DR. STEVEN RAY LARSEN O.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	152W00000X	Optometrist	OPT7687T	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	:	1629194782
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. STEVEN RAY LARSEN O.D.

Provider Business Mailing Address
First Line	:	4096 CENTRE ST
Second Line	:
City	:	SAN DIEGO
State	:	CA
Zip	:	92103-2608
Country	:	US
Telephone Number	:	619-291-5505
Fax Number	:	619-291-4404

Provider Business Practice Location Address
First Line	:	4096 PARK BLVD
Second Line	:
City	:	SAN DIEGO
State	:	CA
Zip	:	92103-2620
Country	:	US
Telephone Number	:	619-291-5505
Fax Number	:	619-291-4404

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

Provider Enumeration Date	:	03/21/2007
Last Update Date	:	10/11/2013

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