Provider Demographics
NPI:1023043262
Name:LARSON, JAMES LIONEL (MD)
Entity Type:Individual
Prefix:
First Name:JAMES
Middle Name:LIONEL
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 1:1543 KINGSLEY AVE
Mailing Address - Street 2:BLDG 14
Mailing Address - City:ORANGE PARK
Mailing Address - State:FL
Mailing Address - Zip Code:32073-4535
Mailing Address - Country:US
Mailing Address - Phone:904-264-6977
Mailing Address - Fax:904-269-0870
Practice Address - Street 1:1543 KINGSLEY AVE
Practice Address - Street 2:BLDG 14
Practice Address - City:ORANGE PARK
Practice Address - State:FL
Practice Address - Zip Code:32073-4535
Practice Address - Country:US
Practice Address - Phone:904-264-6977
Practice Address - Fax:904-269-0870
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-12
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME201702084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL0671240000Medicaid
FL16903WMedicare ID - Type Unspecified
D53083Medicare UPIN