Provider Demographics
NPI:1326426651
Name:LARSON, JOB (MD)
Entity Type:Individual
Prefix:
First Name:JOB
Middle Name:
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:PSC 808 BOX 19
Mailing Address - Street 2:
Mailing Address - City:FPO
Mailing Address - State:AE
Mailing Address - Zip Code:09618-0001
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:278 VT ROUTE 149
Practice Address - Street 2:
Practice Address - City:WEST PAWLET
Practice Address - State:VT
Practice Address - Zip Code:05775-9798
Practice Address - Country:US
Practice Address - Phone:802-645-0580
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-05-06
Last Update Date:2023-08-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VT042.0013562207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine