Provider Demographics
NPI:1003279456
Name:LARSEN, CODY BRAXTON (MD)
Entity Type:Individual
Prefix:DR
First Name:CODY
Middle Name:BRAXTON
Last Name:LARSEN
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 1:263 18TH AVE
Mailing Address - Street 2:
Mailing Address - City:SAN FRANCISCO
Mailing Address - State:CA
Mailing Address - Zip Code:94121-2314
Mailing Address - Country:US
Mailing Address - Phone:415-704-4757
Mailing Address - Fax:
Practice Address - Street 1:800 WHEELING AVE
Practice Address - Street 2:
Practice Address - City:GLEN DALE
Practice Address - State:WV
Practice Address - Zip Code:26038-1660
Practice Address - Country:US
Practice Address - Phone:304-845-3211
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-04-02
Last Update Date:2022-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MA10897300207P00000X
WV29862207P00000X
NY304201207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine