Provider Demographics
NPI:1295865160
Name:LARSON, LUCY KAISER (MD)
Entity Type:Individual
Prefix:MS
First Name:LUCY
Middle Name:KAISER
Last Name:LARSON
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:24255 PACIFIC COAST HWY
Mailing Address - Street 2:PEPPERDINE STUDENT HEALTH CENTER
Mailing Address - City:MALIBU
Mailing Address - State:CA
Mailing Address - Zip Code:90263-3999
Mailing Address - Country:US
Mailing Address - Phone:310-506-4316
Mailing Address - Fax:310-506-4588
Practice Address - Street 1:24255 PACIFIC COAST HWY
Practice Address - Street 2:PEPPERDINE STUDENT HEALTH CENTER
Practice Address - City:MALIBU
Practice Address - State:CA
Practice Address - Zip Code:90263-3999
Practice Address - Country:US
Practice Address - Phone:310-506-4316
Practice Address - Fax:310-506-4588
Is Sole Proprietor?:No
Enumeration Date:2007-03-07
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG62764208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics