Provider Demographics
NPI:1558305532
Name:LARSEN, DONALD W (MD)
Entity Type:Individual
Prefix:DR
First Name:DONALD
Middle Name:W
Last Name:LARSEN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:DONALD
Other - Middle Name:WILLIAM
Other - Last Name:LARSEN
Other - Suffix:JR
Other - Last Name Type:Other Name
Other - Credentials:MD
Mailing Address - Street 1:PO BOX 31309
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90031-0309
Mailing Address - Country:US
Mailing Address - Phone:323-442-5720
Mailing Address - Fax:323-442-7543
Practice Address - Street 1:1520 SAN PABLO ST
Practice Address - Street 2:STE 3800
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90033-5310
Practice Address - Country:US
Practice Address - Phone:323-442-5720
Practice Address - Fax:323-442-7543
Is Sole Proprietor?:No
Enumeration Date:2006-06-16
Last Update Date:2018-01-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG580822085R0204X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0204XAllopathic & Osteopathic PhysiciansRadiologyVascular & Interventional Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
BR640ZOtherPTAN
CA00G580820Medicaid
BR640ZOtherPTAN
BR640ZOtherPTAN