Provider Demographics
NPI:1396755831
Name:LARSON, ALAN WAYNE (MD)
Entity type:Individual
Prefix:
First Name:ALAN
Middle Name:WAYNE
Last Name:LARSON
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 1:15611 POMERADO RD
Mailing Address - Street 2:SUITE 500
Mailing Address - City:POWAY
Mailing Address - State:CA
Mailing Address - Zip Code:92064-2425
Mailing Address - Country:US
Mailing Address - Phone:858-487-2121
Mailing Address - Fax:858-487-3321
Practice Address - Street 1:15611 POMERADO RD
Practice Address - Street 2:SUITE 500
Practice Address - City:POWAY
Practice Address - State:CA
Practice Address - Zip Code:92064-2425
Practice Address - Country:US
Practice Address - Phone:858-487-2121
Practice Address - Fax:858-487-3321
Is Sole Proprietor?:No
Enumeration Date:2006-08-08
Last Update Date:2008-12-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG39334207RG0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA100002787OtherRAILROAD M EDICARE
CA00G393340Medicaid
CAWG39334AMedicare PIN