Individual
DR. LARRY AVIS BOURG
Active
Sole proprietor
No
Provider details
NPI number
Gender
Man
Credential
M.D.
Taxonomy
Speciality
Code
Description
License number
State
174400000X
Specialist
Primary
39560
CO
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
013365
KAISER COMMERCIAL NUMBER
CO
05
—
93909365
—
CO
Enumeration date
02/15/2006
Last updated
08/08/2023
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