Provider Demographics
NPI:1174884456
Name:CLARK, LARRY ANDREW
Entity type:Individual
Prefix:
First Name:LARRY
Middle Name:ANDREW
Last Name:CLARK
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:435 N ROXBURY DR
Mailing Address - Street 2:STE 100
Mailing Address - City:BEVERLY HILLS
Mailing Address - State:CA
Mailing Address - Zip Code:90210-5027
Mailing Address - Country:US
Mailing Address - Phone:310-855-8058
Mailing Address - Fax:310-855-8059
Practice Address - Street 1:435 N ROXBURY DR
Practice Address - Street 2:STE 100
Practice Address - City:BEVERLY HILLS
Practice Address - State:CA
Practice Address - Zip Code:90210-5027
Practice Address - Country:US
Practice Address - Phone:310-855-8058
Practice Address - Fax:310-855-8059
Is Sole Proprietor?:Yes
Enumeration Date:2012-06-04
Last Update Date:2012-06-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA124156246ZC0007X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes246ZC0007XTechnologists, Technicians & Other Technical Service ProvidersSpecialist/Technologist, OtherSurgical Assistant