Provider Demographics
NPI:1770644767
Name:LARSON, MARK DUANE (MD)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:DUANE
Last Name:LARSON
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
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Mailing Address - Street 1:755 N 11TH ST STE P1000
Mailing Address - Street 2:
Mailing Address - City:BEAUMONT
Mailing Address - State:TX
Mailing Address - Zip Code:77702-1528
Mailing Address - Country:US
Mailing Address - Phone:409-833-0193
Mailing Address - Fax:409-833-3346
Practice Address - Street 1:755 N 11TH ST STE P1000
Practice Address - Street 2:
Practice Address - City:BEAUMONT
Practice Address - State:TX
Practice Address - Zip Code:77702-1528
Practice Address - Country:US
Practice Address - Phone:409-833-0193
Practice Address - Fax:409-833-3346
Is Sole Proprietor?:No
Enumeration Date:2006-12-13
Last Update Date:2020-03-09
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
TXH8192208200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208200000XAllopathic & Osteopathic PhysiciansPlastic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX8539K1Medicare PIN