Provider Demographics
NPI:1649295676
Name:COUTURE, LARRY H (MD)
Entity type:Individual
Prefix:
First Name:LARRY
Middle Name:H
Last Name:COUTURE
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 1:6848 MAGNOLIA AVE STE 230
Mailing Address - Street 2:
Mailing Address - City:RIVERSIDE
Mailing Address - State:CA
Mailing Address - Zip Code:92506-2858
Mailing Address - Country:US
Mailing Address - Phone:951-682-9911
Mailing Address - Fax:951-682-9912
Practice Address - Street 1:6848 MAGNOLIA AVE STE 230
Practice Address - Street 2:
Practice Address - City:RIVERSIDE
Practice Address - State:CA
Practice Address - Zip Code:92506-2858
Practice Address - Country:US
Practice Address - Phone:951-682-9911
Practice Address - Fax:951-682-9912
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-12
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA63843207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A638430Medicaid
CAZZZ03602ZMedicare ID - Type UnspecifiedGROUP ID
CA00A638430Medicaid
CA00A638433Medicare ID - Type UnspecifiedPPIN