Provider Demographics
NPI:1528090677
Name:LARSON, BRUCE A (MD)
Entity type:Individual
Prefix:DR
First Name:BRUCE
Middle Name:A
Last Name:LARSON
Suffix:
Gender:M
Credentials:MD
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Mailing Address - Street 1:637 SOUTH LUCAS AVENUE
Mailing Address - Street 2:SUITE 400
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90017-2395
Mailing Address - Country:US
Mailing Address - Phone:213-977-0520
Mailing Address - Fax:213-977-0504
Practice Address - Street 1:637 SOUTH LUCAS AVENUE
Practice Address - Street 2:SUITE 400
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90017-2395
Practice Address - Country:US
Practice Address - Phone:213-977-0520
Practice Address - Fax:213-977-0504
Is Sole Proprietor?:No
Enumeration Date:2006-07-07
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
CAG25228207RE0101X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RE0101XAllopathic & Osteopathic PhysiciansInternal MedicineEndocrinology, Diabetes & Metabolism
Provider Identifiers
StateIdentifier IDID TypeIssuer
A42579Medicare UPIN
G25228Medicare ID - Type Unspecified