Provider Demographics
NPI:1083991400
Name:LARRY D JENSEN DPM PC
Entity Type:Organization
Organization Name:LARRY D JENSEN DPM PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:LARRY
Authorized Official - Middle Name:DEAN
Authorized Official - Last Name:JENSEN
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:503-639-8107
Mailing Address - Street 1:11815 SW KING JAMES PL
Mailing Address - Street 2:SUITE 60
Mailing Address - City:TIGARD
Mailing Address - State:OR
Mailing Address - Zip Code:97224-2478
Mailing Address - Country:US
Mailing Address - Phone:503-639-8107
Mailing Address - Fax:503-639-8108
Practice Address - Street 1:11815 SW KING JAMES PL
Practice Address - Street 2:SUITE 60
Practice Address - City:TIGARD
Practice Address - State:OR
Practice Address - Zip Code:97224-2478
Practice Address - Country:US
Practice Address - Phone:503-639-8107
Practice Address - Fax:503-639-8108
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-11-14
Last Update Date:2012-05-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORDP00199213ES0131X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213ES0131XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR500642371Medicaid
OR500642371Medicaid
OR0876540001Medicare NSC