Provider Demographics
NPI:1629029442
Name:LARSON, ELLEN M (MD)
Entity Type:Individual
Prefix:DR
First Name:ELLEN
Middle Name:M
Last Name:LARSON
Suffix:
Gender:F
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 725
Mailing Address - Street 2:
Mailing Address - City:COOPERSTOWN
Mailing Address - State:NY
Mailing Address - Zip Code:13326-0725
Mailing Address - Country:US
Mailing Address - Phone:315-825-3111
Mailing Address - Fax:315-825-3017
Practice Address - Street 1:140 BROAD ST
Practice Address - Street 2:
Practice Address - City:HAMILTON
Practice Address - State:NY
Practice Address - Zip Code:13346-9575
Practice Address - Country:US
Practice Address - Phone:315-228-7750
Practice Address - Fax:315-228-6823
Is Sole Proprietor?:No
Enumeration Date:2006-05-15
Last Update Date:2023-11-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY217285207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02194558Medicaid
NYH29589Medicare UPIN
NY02194558Medicaid