Provider Demographics
NPI:1356862015
Name:LARSEN, GREGORY PAUL (DPM)
Entity Type:Individual
Prefix:
First Name:GREGORY
Middle Name:PAUL
Last Name:LARSEN
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:13525 CENTERBROOK STE 104
Mailing Address - Street 2:
Mailing Address - City:UNIVERSAL CITY
Mailing Address - State:TX
Mailing Address - Zip Code:78148-2734
Mailing Address - Country:US
Mailing Address - Phone:210-375-3318
Mailing Address - Fax:210-257-6931
Practice Address - Street 1:13525 CENTERBROOK STE 104
Practice Address - Street 2:
Practice Address - City:UNIVERSAL CITY
Practice Address - State:TX
Practice Address - Zip Code:78148-2734
Practice Address - Country:US
Practice Address - Phone:210-375-3318
Practice Address - Fax:210-257-6931
Is Sole Proprietor?:No
Enumeration Date:2017-07-03
Last Update Date:2020-08-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX30491213ES0103X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle Surgery