Provider Demographics
NPI:1821029869
Name:LARCOM, PETER G (MD)
Entity Type:Individual
Prefix:
First Name:PETER
Middle Name:G
Last Name:LARCOM
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:5316 S WOODROW ST STE 200
Mailing Address - Street 2:
Mailing Address - City:MURRAY
Mailing Address - State:UT
Mailing Address - Zip Code:84107-5838
Mailing Address - Country:US
Mailing Address - Phone:801-747-1020
Mailing Address - Fax:801-747-1023
Practice Address - Street 1:5316 S WOODROW ST STE 200
Practice Address - Street 2:
Practice Address - City:MURRAY
Practice Address - State:UT
Practice Address - Zip Code:84107-5838
Practice Address - Country:US
Practice Address - Phone:801-747-1020
Practice Address - Fax:801-747-1023
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-06
Last Update Date:2019-01-03
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
UT321930-1205207XS0114X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207XS0114XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryAdult Reconstructive Orthopaedic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
UTG08328Medicare UPIN
UT000012368Medicare ID - Type Unspecified