Provider Demographics
NPI:1487699013
Name:MOWATT-LARSSEN, ERIC (MD)
Entity type:Individual
Prefix:DR
First Name:ERIC
Middle Name:
Last Name:MOWATT-LARSSEN
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 1:977 PACIFIC ST STE B
Mailing Address - Street 2:
Mailing Address - City:MONTEREY
Mailing Address - State:CA
Mailing Address - Zip Code:93940-4400
Mailing Address - Country:US
Mailing Address - Phone:831-646-8346
Mailing Address - Fax:831-646-8346
Practice Address - Street 1:977 PACIFIC ST STE B
Practice Address - Street 2:
Practice Address - City:MONTEREY
Practice Address - State:CA
Practice Address - Zip Code:93940-4400
Practice Address - Country:US
Practice Address - Phone:831-646-8346
Practice Address - Fax:831-646-8346
Is Sole Proprietor?:No
Enumeration Date:2006-06-18
Last Update Date:2021-02-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101230922207P00000X
CAC55209202K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes202K00000XAllopathic & Osteopathic PhysiciansPhlebology
No207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA235963OtherBLUE SHIELD
VA5861047Medicaid
NC5910835Medicaid
VA930107776OtherRAILROAD MEDICARE
VAH38685Medicare UPIN
NC2023316AMedicare PIN
VA930002093Medicare ID - Type Unspecified
VA5861047Medicaid