Provider Demographics
NPI:1568497519
Name:WEISENTHAL, LARRY MARK (MD, PHD)
Entity Type:Individual
Prefix:DR
First Name:LARRY
Middle Name:MARK
Last Name:WEISENTHAL
Suffix:
Gender:M
Credentials:MD, PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:16512 BURKE LANE
Mailing Address - Street 2:
Mailing Address - City:HUNTINGTON BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:92647-4538
Mailing Address - Country:US
Mailing Address - Phone:714-596-2100
Mailing Address - Fax:714-596-2110
Practice Address - Street 1:16512 BURKE LANE
Practice Address - Street 2:
Practice Address - City:HUNTINGTON BEACH
Practice Address - State:CA
Practice Address - Zip Code:92647-4538
Practice Address - Country:US
Practice Address - Phone:714-596-2100
Practice Address - Fax:714-596-2110
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-11
Last Update Date:2012-05-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA66724207RH0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RH0003XAllopathic & Osteopathic PhysiciansInternal MedicineHematology & Oncology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAG41204OtherMEDICARE PROVIDER #