Provider Demographics
NPI:1326189671
Name:LARRY I. EMDUR, D.O., PHD.
Entity Type:Organization
Organization Name:LARRY I. EMDUR, D.O., PHD.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT,OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:LARRY
Authorized Official - Middle Name:I
Authorized Official - Last Name:EMDUR
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:619-286-8803
Mailing Address - Street 1:5173 WARING RD
Mailing Address - Street 2:SUITE 125
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92120-2705
Mailing Address - Country:US
Mailing Address - Phone:619-286-8803
Mailing Address - Fax:619-286-2344
Practice Address - Street 1:5555 RESERVOIR DR
Practice Address - Street 2:201
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92120-5134
Practice Address - Country:US
Practice Address - Phone:619-286-8803
Practice Address - Fax:619-286-2344
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-09
Last Update Date:2012-08-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA20A4940174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAGR0044140OtherMEDI-CA;
CA20A4940OtherCA STATE LICENSE
CAW10998Medicare PIN
CA20A4940OtherCA STATE LICENSE