Provider Demographics
NPI:1124183686
Name:LARSEN, DOUGLAS FLOYD (OD)
Entity Type:Individual
Prefix:DR
First Name:DOUGLAS
Middle Name:FLOYD
Last Name:LARSEN
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
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Other - Credentials:
Mailing Address - Street 1:41238 MARGARITA RD
Mailing Address - Street 2:SUITE 105
Mailing Address - City:TEMECULA
Mailing Address - State:CA
Mailing Address - Zip Code:92591-5552
Mailing Address - Country:US
Mailing Address - Phone:951-699-1111
Mailing Address - Fax:951-699-0101
Practice Address - Street 1:41238 MARGARITA RD
Practice Address - Street 2:SUITE 105
Practice Address - City:TEMECULA
Practice Address - State:CA
Practice Address - Zip Code:92591-5552
Practice Address - Country:US
Practice Address - Phone:951-699-1111
Practice Address - Fax:951-699-0101
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-26
Last Update Date:2013-03-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA8403T152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA8403TOtherSTATE LICENSE
CAT10684Medicare UPIN