Provider Demographics
NPI:1790300143
Name:LARSON, SPENCER (DO)
Entity Type:Individual
Prefix:DR
First Name:SPENCER
Middle Name:
Last Name:LARSON
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:267 E VENTURA BLVD
Mailing Address - Street 2:
Mailing Address - City:STANSBURY PARK
Mailing Address - State:UT
Mailing Address - Zip Code:84074-9327
Mailing Address - Country:US
Mailing Address - Phone:801-854-8629
Mailing Address - Fax:
Practice Address - Street 1:2376 N 400 E STE 102
Practice Address - Street 2:
Practice Address - City:TOOELE
Practice Address - State:UT
Practice Address - Zip Code:84074-3413
Practice Address - Country:US
Practice Address - Phone:435-843-1225
Practice Address - Fax:435-843-1228
Is Sole Proprietor?:No
Enumeration Date:2020-06-11
Last Update Date:2023-09-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT13185617-1204207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine