Provider Demographics
NPI:1609921204
Name:LARSON, BRENT RAYMOND (MD)
Entity Type:Individual
Prefix:
First Name:BRENT
Middle Name:RAYMOND
Last Name:LARSON
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:210 N TUSTIN AVE
Mailing Address - Street 2:
Mailing Address - City:SANTA ANA
Mailing Address - State:CA
Mailing Address - Zip Code:92705-3807
Mailing Address - Country:US
Mailing Address - Phone:714-347-1012
Mailing Address - Fax:714-647-1245
Practice Address - Street 1:1393 SANTA RITA RD
Practice Address - Street 2:SUITE F
Practice Address - City:PLEASANTON
Practice Address - State:CA
Practice Address - Zip Code:94566-5665
Practice Address - Country:US
Practice Address - Phone:925-462-2334
Practice Address - Fax:925-462-2335
Is Sole Proprietor?:No
Enumeration Date:2007-01-24
Last Update Date:2008-11-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA63652207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A636520Medicaid
CA00A636520Medicaid
H14037Medicare UPIN
CA00A636520Medicare PIN
CAP00632328Medicare PIN