Provider Demographics
NPI:1174630305
Name:LARDON, MICHAEL THEODORE (MD)
Entity type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:THEODORE
Last Name:LARDON
Suffix:
Gender:M
Credentials:MD
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Mailing Address - Street 1:3750 CONVOY ST
Mailing Address - Street 2:SUITE 318
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92111-3738
Mailing Address - Country:US
Mailing Address - Phone:858-292-2929
Mailing Address - Fax:858-292-2909
Practice Address - Street 1:3750 CONVOY ST
Practice Address - Street 2:SUITE 318
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92111-3738
Practice Address - Country:US
Practice Address - Phone:858-292-2929
Practice Address - Fax:858-292-2909
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-24
Last Update Date:2007-07-08
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
CAA486642084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A486641Medicaid
CA00A486641Medicaid
CAE89522Medicare UPIN