Provider Demographics
NPI:1851390108
Name:LARSEN, DAVID T (MD)
Entity Type:Individual
Prefix:
First Name:DAVID
Middle Name:T
Last Name:LARSEN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3000 CORPORATE CT
Mailing Address - Street 2:SUITE 400
Mailing Address - City:FLOWER MOUND
Mailing Address - State:TX
Mailing Address - Zip Code:75028-2299
Mailing Address - Country:US
Mailing Address - Phone:214-647-6165
Mailing Address - Fax:214-647-6166
Practice Address - Street 1:3000 CORPORATE CT
Practice Address - Street 2:SUITE 400
Practice Address - City:FLOWER MOUND
Practice Address - State:TX
Practice Address - Zip Code:75028-2299
Practice Address - Country:US
Practice Address - Phone:214-647-6165
Practice Address - Fax:214-647-6166
Is Sole Proprietor?:No
Enumeration Date:2005-07-19
Last Update Date:2010-08-02
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
TXF97112085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX138590810Medicaid
TX80R349Medicare ID - Type Unspecified
TX138590810Medicaid