Provider Demographics
NPI:1083697635
Name:LARSON, WILLIAM DAVID (MD)
Entity Type:Individual
Prefix:
First Name:WILLIAM
Middle Name:DAVID
Last Name:LARSON
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:W
Other - Middle Name:DAVID
Other - Last Name:LARSON
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MD
Mailing Address - Street 1:6420 SW MACADAM AVE
Mailing Address - Street 2:SUITE 216
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97239-3507
Mailing Address - Country:US
Mailing Address - Phone:503-244-8601
Mailing Address - Fax:503-244-3013
Practice Address - Street 1:19250 SW 65TH AVE
Practice Address - Street 2:STE 215
Practice Address - City:TUALATIN
Practice Address - State:OR
Practice Address - Zip Code:97062-7452
Practice Address - Country:US
Practice Address - Phone:503-692-3630
Practice Address - Fax:503-692-3420
Is Sole Proprietor?:No
Enumeration Date:2005-11-28
Last Update Date:2013-05-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORMD10715207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR060087Medicaid
OR180002095OtherRAILROAD MEDICARE
OR00WCQKQAMedicare PIN
OR060087Medicaid