Provider Demographics
NPI:1003064999
Name:LARSON, DOUGLAS GLEN (MD)
Entity Type:Individual
Prefix:DR
First Name:DOUGLAS
Middle Name:GLEN
Last Name:LARSON
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 1:2020 PALOMINO LN
Mailing Address - Street 2:#100
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89106-4842
Mailing Address - Country:US
Mailing Address - Phone:702-759-8600
Mailing Address - Fax:
Practice Address - Street 1:2020 PALOMINO LN
Practice Address - Street 2:#100
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89106-4842
Practice Address - Country:US
Practice Address - Phone:702-759-8600
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-09-04
Last Update Date:2016-10-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NV153052085R0202X
ORMD1721832085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA1003064999Medicaid
NVP01418514OtherRR MEDICARE DRS
NVP01352399OtherRR DR
ORR190141Medicare PIN
NVV107651Medicare PIN
NVV107650Medicare PIN
ORR189964Medicare PIN