Provider Demographics
NPI:1144212192
Name:LARSON, DAVID M (MD)
Entity Type:Individual
Prefix:
First Name:DAVID
Middle Name:M
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 1:2223 E BASELINE RD
Mailing Address - Street 2:SUITE A
Mailing Address - City:GILBERT
Mailing Address - State:AZ
Mailing Address - Zip Code:85234-2325
Mailing Address - Country:US
Mailing Address - Phone:480-835-5302
Mailing Address - Fax:480-844-2081
Practice Address - Street 1:2223 E BASELINE RD
Practice Address - Street 2:SUITE A
Practice Address - City:GILBERT
Practice Address - State:AZ
Practice Address - Zip Code:85234-2325
Practice Address - Country:US
Practice Address - Phone:480-835-5302
Practice Address - Fax:480-844-2081
Is Sole Proprietor?:No
Enumeration Date:2005-08-16
Last Update Date:2011-05-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ12943208C00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208C00000XAllopathic & Osteopathic PhysiciansColon & Rectal Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
D44141Medicare UPIN