Provider Demographics
NPI:1518042571
Name:LARSEN, RODNEY J (MD)
Entity Type:Individual
Prefix:
First Name:RODNEY
Middle Name:J
Last Name:LARSEN
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 1:1 S END BRIDGE CIR
Mailing Address - Street 2:
Mailing Address - City:AGAWAM
Mailing Address - State:MA
Mailing Address - Zip Code:01001-2020
Mailing Address - Country:US
Mailing Address - Phone:413-786-9636
Mailing Address - Fax:413-789-6818
Practice Address - Street 1:1 S END BRIDGE CIR
Practice Address - Street 2:
Practice Address - City:AGAWAM
Practice Address - State:MA
Practice Address - Zip Code:01001-2020
Practice Address - Country:US
Practice Address - Phone:413-786-9636
Practice Address - Fax:413-789-6818
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-26
Last Update Date:2008-06-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA38727174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA2058146Medicaid
MA2058146Medicaid