Provider Demographics
NPI:1588603666
Name:LARSON, JAY (MD)
Entity Type:Individual
Prefix:
First Name:JAY
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 1:301 SADDLE DR
Mailing Address - Street 2:SUITE D
Mailing Address - City:HELENA
Mailing Address - State:MT
Mailing Address - Zip Code:59601-8098
Mailing Address - Country:US
Mailing Address - Phone:406-442-2205
Mailing Address - Fax:406-442-2445
Practice Address - Street 1:301 SADDLE DR
Practice Address - Street 2:
Practice Address - City:HELENA
Practice Address - State:MT
Practice Address - Zip Code:59601-8098
Practice Address - Country:US
Practice Address - Phone:406-442-2205
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-06-05
Last Update Date:2017-02-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MT6629207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MT0143174Medicaid
MTE44241Medicare UPIN
MT0143174Medicaid