Provider Demographics
NPI:1386654119
Name:LARSEN, GEORGE DOUGLAS (MD)
Entity Type:Individual
Prefix:DR
First Name:GEORGE
Middle Name:DOUGLAS
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 1:1414 N AUGUSTA ST
Mailing Address - Street 2:P.O. BOX 2126
Mailing Address - City:STAUNTON
Mailing Address - State:VA
Mailing Address - Zip Code:24401-2401
Mailing Address - Country:US
Mailing Address - Phone:540-332-7830
Mailing Address - Fax:540-885-0149
Practice Address - Street 1:1414 N AUGUSTA ST
Practice Address - Street 2:
Practice Address - City:STAUNTON
Practice Address - State:VA
Practice Address - Zip Code:24401-2401
Practice Address - Country:US
Practice Address - Phone:540-332-7830
Practice Address - Fax:540-885-0149
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-08
Last Update Date:2011-08-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101021588251K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251K00000XAgenciesPublic Health or Welfare
Provider Identifiers
StateIdentifier IDID TypeIssuer
VAF46 532Medicare UPIN