Provider Demographics
NPI:1407896418
Name:LARSON, MICHAEL F (DO)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:F
Last Name:LARSON
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
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Other - Credentials:
Mailing Address - Street 1:147 MILK ST
Mailing Address - Street 2:PROVIDER ENROLLMENT 9TH FLOOR
Mailing Address - City:BOSTON
Mailing Address - State:MA
Mailing Address - Zip Code:02109-4806
Mailing Address - Country:US
Mailing Address - Phone:617-559-8051
Mailing Address - Fax:
Practice Address - Street 1:485 ARSENAL ST
Practice Address - Street 2:
Practice Address - City:WATERTOWN
Practice Address - State:MA
Practice Address - Zip Code:02472-5091
Practice Address - Country:US
Practice Address - Phone:617-972-5540
Practice Address - Fax:617-972-5564
Is Sole Proprietor?:No
Enumeration Date:2006-06-07
Last Update Date:2011-07-14
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MA1608072084P0804X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0804XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyChild & Adolescent Psychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA0037398OtherNEIGHBORHOOD HEALTH PLAN
MA347529OtherTUFTS HEALTH PLAN
MAJ21527OtherBLUE CROSS
MAG99739Medicare UPIN
MAA29987Medicare PIN