Provider Demographics
NPI:1497778054
Name:VAN FOSSEN, LARRY DOUGLAS (DO)
Entity Type:Individual
Prefix:DR
First Name:LARRY
Middle Name:DOUGLAS
Last Name:VAN FOSSEN
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 1:5955 RAND BLVD
Mailing Address - Street 2:
Mailing Address - City:SARASOTA
Mailing Address - State:FL
Mailing Address - Zip Code:34238-5160
Mailing Address - Country:US
Mailing Address - Phone:941-893-6620
Mailing Address - Fax:941-748-8440
Practice Address - Street 1:5955 RAND BLVD
Practice Address - Street 2:
Practice Address - City:SARASOTA
Practice Address - State:FL
Practice Address - Zip Code:34238-5160
Practice Address - Country:US
Practice Address - Phone:941-893-6620
Practice Address - Fax:941-748-8440
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-25
Last Update Date:2023-03-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH34.005429207LH0002X, 207LH0002X
FLOS18532207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207LH0002XAllopathic & Osteopathic PhysiciansAnesthesiologyHospice and Palliative Medicine
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL114329900Medicaid
OH0981826Medicaid
OH300135298OtherRR MEDICARE