Provider Demographics
NPI:1831321546
Name:LARSEN, JEREMY T (MD)
Entity Type:Individual
Prefix:DR
First Name:JEREMY
Middle Name:T
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 1:14200 W CELEBRATE LIFE WAY
Mailing Address - Street 2:
Mailing Address - City:GOODYEAR
Mailing Address - State:AZ
Mailing Address - Zip Code:85338-3007
Mailing Address - Country:US
Mailing Address - Phone:623-207-3000
Mailing Address - Fax:623-207-3921
Practice Address - Street 1:14200 W CELEBRATE LIFE WAY
Practice Address - Street 2:
Practice Address - City:GOODYEAR
Practice Address - State:AZ
Practice Address - Zip Code:85338-3007
Practice Address - Country:US
Practice Address - Phone:623-207-3000
Practice Address - Fax:623-207-3921
Is Sole Proprietor?:No
Enumeration Date:2009-08-13
Last Update Date:2024-01-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ54266207RH0003X
MN53065207R00000X, 207RH0003X
NE29227207RH0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RH0003XAllopathic & Osteopathic PhysiciansInternal MedicineHematology & Oncology
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MNENROLLEDMedicaid
MNP01049419OtherRAILROAD MEDICARE
MNENROLLEDMedicaid