Provider Demographics
NPI:1669416319
Name:FOREMAN, LARRY WARREN (DO)
Entity type:Individual
Prefix:
First Name:LARRY
Middle Name:WARREN
Last Name:FOREMAN
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1945 CORBETT HIGHLANDS PL
Mailing Address - Street 2:
Mailing Address - City:ARROYO GRANDE
Mailing Address - State:CA
Mailing Address - Zip Code:93420-4933
Mailing Address - Country:US
Mailing Address - Phone:805-459-8917
Mailing Address - Fax:
Practice Address - Street 1:1911 JOHNSON AVENUE
Practice Address - Street 2:
Practice Address - City:SAN LUIS OBISPO
Practice Address - State:CA
Practice Address - Zip Code:93401
Practice Address - Country:US
Practice Address - Phone:805-543-5353
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-06-15
Last Update Date:2016-06-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA20A5055207P00000X, 207PH0002X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207PH0002XAllopathic & Osteopathic PhysiciansEmergency MedicineHospice and Palliative Medicine
No207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00AX50550Medicaid
CAHW8306VMedicare PIN
CAD13989Medicare UPIN
CAW20A5055EMedicare PIN