Basic Information
| Provider Information | |||||||||
| NPI: | 1104073709 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | LARSEN | ||||||||
| FirstName: | GREGORY | ||||||||
| MiddleName: | S | ||||||||
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| Credential: | D.O. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 312 NOTRE DAME RD | ||||||||
| Address2: | |||||||||
| City: | CLAREMONT | ||||||||
| State: | CA | ||||||||
| PostalCode: | 917115136 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9093993609 | ||||||||
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| Practice Location | |||||||||
| Address1: | 400 N PEPPER AVE | ||||||||
| Address2: | |||||||||
| City: | COLTON | ||||||||
| State: | CA | ||||||||
| PostalCode: | 923241801 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9095801000 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 08/26/2008 | ||||||||
| LastUpdateDate: | 10/30/2009 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207P00000X | 20A10521 | CA | Y | Allopathic & Osteopathic Physicians | Emergency Medicine |
No ID Information.