Provider Demographics
NPI:1336125632
Name:LARSON, SUSAN A (MD)
Entity Type:Individual
Prefix:DR
First Name:SUSAN
Middle Name:A
Last Name:LARSON
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4745 ARAPAHOE AVE
Mailing Address - Street 2:STE 200
Mailing Address - City:BOULDER
Mailing Address - State:CO
Mailing Address - Zip Code:80303-1080
Mailing Address - Country:US
Mailing Address - Phone:303-938-4750
Mailing Address - Fax:303-938-4753
Practice Address - Street 1:4745 ARAPAHOE AVE STE 200
Practice Address - Street 2:
Practice Address - City:BOULDER
Practice Address - State:CO
Practice Address - Zip Code:80303-1082
Practice Address - Country:US
Practice Address - Phone:303-938-4750
Practice Address - Fax:303-938-4753
Is Sole Proprietor?:No
Enumeration Date:2005-12-19
Last Update Date:2021-03-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO38667208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO88455050Medicaid
CO88455050Medicaid
COF79113Medicare UPIN