Provider Demographics
NPI:1417063736
Name:LARSEN, DOUGLAS PHILLIP (DO)
Entity Type:Individual
Prefix:DR
First Name:DOUGLAS
Middle Name:PHILLIP
Last Name:LARSEN
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:103 GREAT OAKS BLVD
Mailing Address - Street 2:
Mailing Address - City:ALBANY
Mailing Address - State:NY
Mailing Address - Zip Code:12203
Mailing Address - Country:US
Mailing Address - Phone:518-464-1392
Mailing Address - Fax:518-464-0445
Practice Address - Street 1:103 GREAT OAKS BLVD
Practice Address - Street 2:
Practice Address - City:ALBANY
Practice Address - State:NY
Practice Address - Zip Code:12203
Practice Address - Country:US
Practice Address - Phone:518-464-1392
Practice Address - Fax:518-464-0445
Is Sole Proprietor?:No
Enumeration Date:2006-08-21
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY119564208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY00427289Medicaid