Provider Demographics
NPI:1629194782
Name:LARSEN, STEVEN RAY (OD)
Entity Type:Individual
Prefix:DR
First Name:STEVEN
Middle Name:RAY
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 1:4096 CENTRE ST
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92103-2608
Mailing Address - Country:US
Mailing Address - Phone:619-291-5505
Mailing Address - Fax:619-291-4404
Practice Address - Street 1:4096 PARK BLVD
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92103-2620
Practice Address - Country:US
Practice Address - Phone:619-291-5505
Practice Address - Fax:619-291-4404
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-21
Last Update Date:2013-10-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAOPT7687T152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CASD0076871Medicaid
CAOP7687Medicare ID - Type UnspecifiedMEDICARE ID NUMBER
CAT70218Medicare UPIN
CAOP7687Medicare PIN