Provider Demographics
NPI:1114018132
Name:MARSHALL, LARRY J (MD)
Entity Type:Individual
Prefix:DR
First Name:LARRY
Middle Name:J
Last Name:MARSHALL
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:12517 LAKESHORE DR
Mailing Address - Street 2:
Mailing Address - City:LAKESIDE
Mailing Address - State:CA
Mailing Address - Zip Code:92040-3103
Mailing Address - Country:US
Mailing Address - Phone:619-443-3843
Mailing Address - Fax:619-390-1810
Practice Address - Street 1:12517 LAKESHORE DR
Practice Address - Street 2:
Practice Address - City:LAKESIDE
Practice Address - State:CA
Practice Address - Zip Code:92040-3103
Practice Address - Country:US
Practice Address - Phone:619-443-3843
Practice Address - Fax:619-390-1810
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-27
Last Update Date:2020-12-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NV16913207Q00000X
CAA52344207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A523440Medicaid
CAG02209Medicare UPIN
CAWA52344CMedicare ID - Type UnspecifiedMEDICARE