Provider Demographics
NPI:1902902653
Name:SNYDER, LARRY (MD)
Entity Type:Individual
Prefix:DR
First Name:LARRY
Middle Name:
Last Name:SNYDER
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:PO BOX 3630
Mailing Address - Street 2:
Mailing Address - City:DANA POINT
Mailing Address - State:CA
Mailing Address - Zip Code:92629
Mailing Address - Country:US
Mailing Address - Phone:949-496-4369
Mailing Address - Fax:949-496-9365
Practice Address - Street 1:34052 LA PLZ
Practice Address - Street 2:SUITE 101
Practice Address - City:DANA POINT
Practice Address - State:CA
Practice Address - Zip Code:92629-2587
Practice Address - Country:US
Practice Address - Phone:949-496-4369
Practice Address - Fax:949-496-9365
Is Sole Proprietor?:No
Enumeration Date:2006-09-16
Last Update Date:2011-11-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAC40002207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAW13226BOtherMEDICARE GROUP NUMBER
CAC40002OtherLICENSE
CAZZZ05180ZOtherBLUE SHIELD
CAC40002OtherLICENSE
CAW13226BOtherMEDICARE GROUP NUMBER