Provider Demographics
NPI:1710194352
Name:LARSSON, ERNST OLOF (MD)
Entity Type:Individual
Prefix:DR
First Name:ERNST
Middle Name:OLOF
Last Name:LARSSON
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 1:176 FREEDOM ROAD
Mailing Address - Street 2:
Mailing Address - City:DRUMS
Mailing Address - State:PA
Mailing Address - Zip Code:18222
Mailing Address - Country:US
Mailing Address - Phone:570-788-2359
Mailing Address - Fax:
Practice Address - Street 1:1702 UNIVERSITY DR S
Practice Address - Street 2:
Practice Address - City:FARGO
Practice Address - State:ND
Practice Address - Zip Code:58103-4940
Practice Address - Country:US
Practice Address - Phone:701-364-4222
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-05-16
Last Update Date:2017-11-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ND7258207R00000X, 208M00000X
PAMD021204E207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No208M00000XAllopathic & Osteopathic PhysiciansHospitalist
Provider Identifiers
StateIdentifier IDID TypeIssuer
04109770871OtherMEDICAL EDUCATION NUMBER
04109770871OtherMEDICAL EDUCATION NUMBER