Provider Demographics
NPI:1508219239
Name:LARSON, BRADLEY (MD)
Entity Type:Individual
Prefix:
First Name:BRADLEY
Middle Name:
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 1:3601 W 13 MILE RD DEPT OF
Mailing Address - Street 2:
Mailing Address - City:ROYAL OAK
Mailing Address - State:MI
Mailing Address - Zip Code:48073-6712
Mailing Address - Country:US
Mailing Address - Phone:248-898-0833
Mailing Address - Fax:
Practice Address - Street 1:3601 W 13 MILE RD DEPT OF
Practice Address - Street 2:
Practice Address - City:ROYAL OAK
Practice Address - State:MI
Practice Address - Zip Code:48073-6712
Practice Address - Country:US
Practice Address - Phone:248-898-0833
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-07-18
Last Update Date:2023-11-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301110680207L00000X
MI4301505299207LP3000X, 207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
No207LP3000XAllopathic & Osteopathic PhysiciansAnesthesiologyPediatric Anesthesiology