Provider Demographics
NPI:1689665002
Name:ROBSON, LARRY J (MD)
Entity Type:Individual
Prefix:DR
First Name:LARRY
Middle Name:J
Last Name:ROBSON
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:PO BOX 152057
Mailing Address - Street 2:
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49515-2057
Mailing Address - Country:US
Mailing Address - Phone:616-885-5000
Mailing Address - Fax:616-913-9025
Practice Address - Street 1:2900 BRADFORD ST NE
Practice Address - Street 2:
Practice Address - City:GRAND RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49525-6427
Practice Address - Country:US
Practice Address - Phone:616-885-5000
Practice Address - Fax:616-913-9025
Is Sole Proprietor?:No
Enumeration Date:2005-11-03
Last Update Date:2010-11-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI43010258282086S0129X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2086S0129XAllopathic & Osteopathic PhysiciansSurgeryVascular Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI4301610Medicaid
MI770002740OtherRAILROAD MEDICARE
MIB44974Medicare UPIN
MI4301610Medicaid