Basic Information
| Provider Information | |||||||||
| NPI: | 1437339264 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | LARSEN | ||||||||
| FirstName: | COREY | ||||||||
| MiddleName: | B. | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 11999 SAN VICENTE BLVD STE 440 | ||||||||
| Address2: | |||||||||
| City: | LOS ANGELES | ||||||||
| State: | CA | ||||||||
| PostalCode: | 900495042 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3104715852 | ||||||||
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| Practice Location | |||||||||
| Address1: | 30745 PACIFIC COAST HWY # 439 | ||||||||
| Address2: | |||||||||
| City: | MALIBU | ||||||||
| State: | CA | ||||||||
| PostalCode: | 902653647 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3108740440 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 11/08/2007 | ||||||||
| LastUpdateDate: | 01/31/2014 | ||||||||
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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 | 207L00000X | G21579 | CA | Y | Allopathic & Osteopathic Physicians | Anesthesiology |
ID Information
| ID | Type | State | Issuer | Description | 00G215790 | 05 | CA | MEDICAID |