Provider Demographics
NPI:1629049473
Name:LARSON, JON (MD)
Entity Type:Individual
Prefix:DR
First Name:JON
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 1:2102 N COUNTRY CLUB RD
Mailing Address - Street 2:BLDG B
Mailing Address - City:TUCSON
Mailing Address - State:AZ
Mailing Address - Zip Code:85716-2831
Mailing Address - Country:US
Mailing Address - Phone:520-795-8371
Mailing Address - Fax:
Practice Address - Street 1:2102 N COUNTRY CLUB RD
Practice Address - Street 2:BLDG B
Practice Address - City:TUCSON
Practice Address - State:AZ
Practice Address - Zip Code:85716-2831
Practice Address - Country:US
Practice Address - Phone:520-795-8371
Practice Address - Fax:
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-01-30
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ10339208100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & Rehabilitation
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZE47396Medicare UPIN
AZZ25WCHRM01Medicare ID - Type Unspecified