Provider Demographics
NPI:1275518631
Name:LARSON, BARRY J (MD)
Entity Type:Individual
Prefix:
First Name:BARRY
Middle Name:J
Last Name:LARSON
Suffix:
Gender:M
Credentials:MD
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Mailing Address - Street 1:3433 BROADWAY STREET NE
Mailing Address - Street 2:SUITE 300
Mailing Address - City:MINNEAPOLIS
Mailing Address - State:MN
Mailing Address - Zip Code:55413-1761
Mailing Address - Country:US
Mailing Address - Phone:763-587-7737
Mailing Address - Fax:763-587-7989
Practice Address - Street 1:3433 BROADWAY STREET NE
Practice Address - Street 2:SUITE 300
Practice Address - City:MINNEAPOLIS
Practice Address - State:MN
Practice Address - Zip Code:55413-1761
Practice Address - Country:US
Practice Address - Phone:763-587-7737
Practice Address - Fax:763-587-7069
Is Sole Proprietor?:No
Enumeration Date:2005-12-08
Last Update Date:2016-11-23
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
MN30136207Q00000X, 207QG0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207QG0300XAllopathic & Osteopathic PhysiciansFamily MedicineGeriatric Medicine
No207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
D75521Medicare UPIN
MND75521Medicare UPIN
D75521Medicare UPIN
MN107582900Medicaid
089000151Medicare PIN