Provider Demographics
NPI:1346335981
Name:LARSEN, DAVID (MD)
Entity Type:Individual
Prefix:DR
First Name:DAVID
Middle Name:
Last Name:LARSEN
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 1:655 LEXINGTON AVE
Mailing Address - Street 2:
Mailing Address - City:JACKSON
Mailing Address - State:TN
Mailing Address - Zip Code:38301-5075
Mailing Address - Country:US
Mailing Address - Phone:731-215-2500
Mailing Address - Fax:731-300-0307
Practice Address - Street 1:655 LEXINGTON AVE
Practice Address - Street 2:
Practice Address - City:JACKSON
Practice Address - State:TN
Practice Address - Zip Code:38301-5075
Practice Address - Country:US
Practice Address - Phone:731-215-2500
Practice Address - Fax:731-300-0307
Is Sole Proprietor?:No
Enumeration Date:2006-10-03
Last Update Date:2018-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNMD0000009731207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN3189319Medicaid
TN744524OtherFIRST HEALTH
TN080099502OtherRAILROAD MEDICARE
TN4277358OtherAETNA
TN000000009028OtherTLC
TN0017809OtherBLUE CROSS BLUE SHIELD
TN3189319Medicaid
TN3189319Medicare ID - Type Unspecified