Provider Demographics
NPI:1033295787
Name:LARSON, ERIC B
Entity Type:Individual
Prefix:
First Name:ERIC
Middle Name:B
Last Name:LARSON
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 50095
Mailing Address - Street 2:
Mailing Address - City:SEATTLE
Mailing Address - State:WA
Mailing Address - Zip Code:98145-5095
Mailing Address - Country:US
Mailing Address - Phone:206-543-6420
Mailing Address - Fax:
Practice Address - Street 1:UWMC-ROOSEVELT
Practice Address - Street 2:4245 ROOSEVELT WAY NE
Practice Address - City:SEATTLE
Practice Address - State:WA
Practice Address - Zip Code:98105-6920
Practice Address - Country:US
Practice Address - Phone:206-598-8750
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-10-27
Last Update Date:2013-01-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMD00014531207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA0231513OtherL&I
0999OtherINTERNAL ID-MOTOR VEHICLE ID
WA1033295787Medicaid
0999OtherINTERNAL ID-MOTOR VEHICLE ID
WA0231513OtherL&I