Provider Demographics
NPI:1346399292
Name:LARSSON, JAN OLOF
Entity Type:Individual
Prefix:DR
First Name:JAN
Middle Name:OLOF
Last Name:LARSSON
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:16121 MORRISON ST
Mailing Address - Street 2:
Mailing Address - City:ENCINO
Mailing Address - State:CA
Mailing Address - Zip Code:91436-1329
Mailing Address - Country:US
Mailing Address - Phone:760-641-1692
Mailing Address - Fax:818-783-5938
Practice Address - Street 1:18055 VENTURA BLVD
Practice Address - Street 2:
Practice Address - City:ENCINO
Practice Address - State:CA
Practice Address - Zip Code:91316-3517
Practice Address - Country:US
Practice Address - Phone:760-641-1692
Practice Address - Fax:818-783-5938
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-09
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA52928207Q00000X, 207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Not Answered207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAA52928OtherSTATE LICENCE, ALSO IN NY
CAA52928OtherSTATE LICENCE, ALSO IN NY