Provider Demographics
NPI:1700414596
Name:LARSON, PRATHYUSHA PAMIDI (DO)
Entity Type:Individual
Prefix:DR
First Name:PRATHYUSHA
Middle Name:PAMIDI
Last Name:LARSON
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1910 HILLBROOKE TRL STE 2
Mailing Address - Street 2:
Mailing Address - City:TALLAHASSEE
Mailing Address - State:FL
Mailing Address - Zip Code:32311-7914
Mailing Address - Country:US
Mailing Address - Phone:850-878-2637
Mailing Address - Fax:850-878-2053
Practice Address - Street 1:1910 HILLBROOKE TRL STE 2
Practice Address - Street 2:
Practice Address - City:TALLAHASSEE
Practice Address - State:FL
Practice Address - Zip Code:32311-7914
Practice Address - Country:US
Practice Address - Phone:850-878-2637
Practice Address - Fax:850-878-2053
Is Sole Proprietor?:No
Enumeration Date:2020-03-29
Last Update Date:2023-08-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
FLOS20091207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program