Provider Demographics
NPI:1417167628
Name:LARSON, DONALD MELVIN (MD)
Entity Type:Individual
Prefix:DR
First Name:DONALD
Middle Name:MELVIN
Last Name:LARSON
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 1:2866 LILAC LN N
Mailing Address - Street 2:
Mailing Address - City:FARGO
Mailing Address - State:ND
Mailing Address - Zip Code:58102-1703
Mailing Address - Country:US
Mailing Address - Phone:701-293-5167
Mailing Address - Fax:
Practice Address - Street 1:2866 LILAC LN N
Practice Address - Street 2:
Practice Address - City:FARGO
Practice Address - State:ND
Practice Address - Zip Code:58102-1703
Practice Address - Country:US
Practice Address - Phone:701-293-5167
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-23
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ND29872084N0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NDD26059Medicare ID - Type Unspecified