Provider Demographics
NPI:1578599304
Name:LARSON, GARY L (MD)
Entity Type:Individual
Prefix:
First Name:GARY
Middle Name:L
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:PO BOX 248856
Mailing Address - Street 2:
Mailing Address - City:OKLAHOMA CITY
Mailing Address - State:OK
Mailing Address - Zip Code:73124-8856
Mailing Address - Country:US
Mailing Address - Phone:405-607-4520
Mailing Address - Fax:405-607-4525
Practice Address - Street 1:5911 W MEMORIAL RD
Practice Address - Street 2:
Practice Address - City:OKLAHOMA CITY
Practice Address - State:OK
Practice Address - Zip Code:73142-2015
Practice Address - Country:US
Practice Address - Phone:405-773-6530
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-06-23
Last Update Date:2023-06-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK138562085R0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0001XAllopathic & Osteopathic PhysiciansRadiologyRadiation Oncology
Provider Identifiers
StateIdentifier IDID TypeIssuer
300042703OtherRAILROAD MEDICARE
OK100088460AMedicaid
OK100088460AMedicaid
OK402564Medicare PIN