Provider Demographics
NPI:1629036645
Name:LARSON, GREGORY R (MD)
Entity Type:Individual
Prefix:
First Name:GREGORY
Middle Name:R
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 1:506 1ST AVE SE
Mailing Address - Street 2:
Mailing Address - City:WATERTOWN
Mailing Address - State:SD
Mailing Address - Zip Code:57201-4402
Mailing Address - Country:US
Mailing Address - Phone:605-886-8482
Mailing Address - Fax:605-884-4300
Practice Address - Street 1:511 14TH AVE NE
Practice Address - Street 2:
Practice Address - City:WATERTOWN
Practice Address - State:SD
Practice Address - Zip Code:57201-6811
Practice Address - Country:US
Practice Address - Phone:605-886-8482
Practice Address - Fax:605-884-4300
Is Sole Proprietor?:No
Enumeration Date:2006-05-01
Last Update Date:2022-05-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SD3698207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
SD5609624Medicaid
SD5609624Medicaid
SD080172782Medicare PIN
SDS8072Medicare PIN