Provider Demographics
NPI:1083239727
Name:LARISSA LARSEN DERMATOLOGY INC
Entity Type:Organization
Organization Name:LARISSA LARSEN DERMATOLOGY INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:LARISSA
Authorized Official - Middle Name:NADIA
Authorized Official - Last Name:LARSEN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:805-807-2367
Mailing Address - Street 1:2460 N PONDEROSA DR STE A117
Mailing Address - Street 2:
Mailing Address - City:CAMARILLO
Mailing Address - State:CA
Mailing Address - Zip Code:93010-2468
Mailing Address - Country:US
Mailing Address - Phone:805-430-0002
Mailing Address - Fax:
Practice Address - Street 1:2460 N PONDEROSA DR STE A117
Practice Address - Street 2:
Practice Address - City:CAMARILLO
Practice Address - State:CA
Practice Address - Zip Code:93010-2468
Practice Address - Country:US
Practice Address - Phone:805-430-0002
Practice Address - Fax:805-389-1245
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-06-09
Last Update Date:2023-11-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatologyGroup - Single Specialty
No261QM2500XAmbulatory Health Care FacilitiesClinic/CenterMedical SpecialtyGroup - Single Specialty