Provider Demographics
NPI:1477581528
Name:LARSON, DAVID E (MD)
Entity Type:Individual
Prefix:
First Name:DAVID
Middle Name:E
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 1:1120 N. MARR ROAD
Mailing Address - Street 2:
Mailing Address - City:COLUMBUS
Mailing Address - State:IN
Mailing Address - Zip Code:47201-5501
Mailing Address - Country:US
Mailing Address - Phone:812-376-9219
Mailing Address - Fax:812-378-4821
Practice Address - Street 1:1120 N MARR RD
Practice Address - Street 2:
Practice Address - City:COLUMBUS
Practice Address - State:IN
Practice Address - Zip Code:47201-5505
Practice Address - Country:US
Practice Address - Phone:812-376-9219
Practice Address - Fax:812-378-4821
Is Sole Proprietor?:No
Enumeration Date:2006-06-29
Last Update Date:2012-12-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN1023925208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN100358610Medicaid