Provider Demographics
NPI:1457467003
Name:LARSEN, TERESA KAY (DO)
Entity Type:Individual
Prefix:DR
First Name:TERESA
Middle Name:KAY
Last Name:LARSEN
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5325 SOM CENTER RD
Mailing Address - Street 2:
Mailing Address - City:SOLON
Mailing Address - State:OH
Mailing Address - Zip Code:44139-1459
Mailing Address - Country:US
Mailing Address - Phone:440-785-5278
Mailing Address - Fax:440-394-8132
Practice Address - Street 1:5325 SOM CENTER RD
Practice Address - Street 2:
Practice Address - City:SOLON
Practice Address - State:OH
Practice Address - Zip Code:44139-1459
Practice Address - Country:US
Practice Address - Phone:440-785-5278
Practice Address - Fax:440-394-8132
Is Sole Proprietor?:No
Enumeration Date:2006-08-23
Last Update Date:2016-11-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH34-007383208100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & Rehabilitation
Provider Identifiers
StateIdentifier IDID TypeIssuer
000000523573OtherANTHEM PIN
OH2283818Medicaid
OH2283818Medicaid
000000523573OtherANTHEM PIN
OH4065201Medicare PIN
H53384Medicare UPIN