Provider Demographics
NPI:1407895964
Name:LARSEN, JASON MARK (OD)
Entity Type:Individual
Prefix:DR
First Name:JASON
Middle Name:MARK
Last Name:LARSEN
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2524 WESTSIDE RD
Mailing Address - Street 2:
Mailing Address - City:YREKA
Mailing Address - State:CA
Mailing Address - Zip Code:96097-9129
Mailing Address - Country:US
Mailing Address - Phone:530-842-2760
Mailing Address - Fax:
Practice Address - Street 1:2524 WESTSIDE RD
Practice Address - Street 2:
Practice Address - City:YREKA
Practice Address - State:CA
Practice Address - Zip Code:96097-9129
Practice Address - Country:US
Practice Address - Phone:530-842-2760
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-06-06
Last Update Date:2007-12-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAOPT12133TPA152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CASDO121330Medicaid
CAZZZ13445ZOtherMEDICARE GROUP NUMBER
CASDO121330Medicaid
CASD0121330Medicare PIN