Provider Demographics
NPI:1104864354
Name:LARSON, JOHN R (MD)
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:R
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:PO BOX 2197
Mailing Address - Street 2:
Mailing Address - City:BATESVILLE
Mailing Address - State:AR
Mailing Address - Zip Code:72503-2197
Mailing Address - Country:US
Mailing Address - Phone:870-262-6155
Mailing Address - Fax:870-262-6152
Practice Address - Street 1:1215 SIDNEY ST
Practice Address - Street 2:SUITE 203
Practice Address - City:BATESVILLE
Practice Address - State:AR
Practice Address - Zip Code:72501-7203
Practice Address - Country:US
Practice Address - Phone:870-262-6155
Practice Address - Fax:870-262-6152
Is Sole Proprietor?:No
Enumeration Date:2006-06-02
Last Update Date:2024-04-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARE7818207LP2900X
ARE-7818207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
No207LP2900XAllopathic & Osteopathic PhysiciansAnesthesiologyPain Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR264659YMPROtherMEDICARE
AR195965001Medicaid
AR51281OtherBLUE CROSS BLUE SHIELD
ARE-7818OtherSTATE LICENSE