Provider Demographics
NPI:1790095032
Name:LARSEN, ROBERT GLEN (MD)
Entity Type:Individual
Prefix:DR
First Name:ROBERT
Middle Name:GLEN
Last Name:LARSEN
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 1:7411 263RD ST APT A1
Mailing Address - Street 2:
Mailing Address - City:GLEN OAKS
Mailing Address - State:NY
Mailing Address - Zip Code:11004-1161
Mailing Address - Country:US
Mailing Address - Phone:503-330-6123
Mailing Address - Fax:
Practice Address - Street 1:7411 263RD ST APT A1
Practice Address - Street 2:
Practice Address - City:GLEN OAKS
Practice Address - State:NY
Practice Address - Zip Code:11004-1161
Practice Address - Country:US
Practice Address - Phone:503-330-6123
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-10-20
Last Update Date:2010-10-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY60-258701207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine