Provider Demographics
NPI:1528183928
Name:LARSON, CRAIG R
Entity Type:Individual
Prefix:DR
First Name:CRAIG
Middle Name:R
Last Name:LARSON
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 1:8010 FROST ST STE 408
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92123-4222
Mailing Address - Country:US
Mailing Address - Phone:858-939-7471
Mailing Address - Fax:858-939-7472
Practice Address - Street 1:8010 FROST ST STE 408
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92123-4222
Practice Address - Country:US
Practice Address - Phone:858-939-7471
Practice Address - Fax:858-939-7472
Is Sole Proprietor?:No
Enumeration Date:2007-03-21
Last Update Date:2016-10-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA20A11358208G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208G00000XAllopathic & Osteopathic PhysiciansThoracic Surgery (Cardiothoracic Vascular Surgery)
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAW16526Medicare UPIN