Provider Demographics
NPI:1578592838
Name:LARSON, ERIC WINDSOR SR (SUBMARINE IDC)
Entity Type:Individual
Prefix:
First Name:ERIC
Middle Name:WINDSOR
Last Name:LARSON
Suffix:SR
Gender:M
Credentials:SUBMARINE IDC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:117 BETTINGER PL
Mailing Address - Street 2:
Mailing Address - City:SAINT MARYS
Mailing Address - State:GA
Mailing Address - Zip Code:31558-4665
Mailing Address - Country:US
Mailing Address - Phone:912-576-1541
Mailing Address - Fax:
Practice Address - Street 1:580 USS MARIANO G VALLEJO AVE
Practice Address - Street 2:NSSC MEDICAL KINGS BAY
Practice Address - City:KINGS BAY
Practice Address - State:GA
Practice Address - Zip Code:31547
Practice Address - Country:US
Practice Address - Phone:912-573-2939
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-30
Last Update Date:2008-09-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1710I1002XOther Service ProvidersMilitary Health Care ProviderIndependent Duty Corpsman