Provider Demographics
NPI:1861498370
Name:LARSON, BRIAN J (MD)
Entity Type:Individual
Prefix:
First Name:BRIAN
Middle Name:J
Last Name:LARSON
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 1:3485 INDEPENDENCE DR
Mailing Address - Street 2:
Mailing Address - City:HOMEWOOD
Mailing Address - State:AL
Mailing Address - Zip Code:35209-5603
Mailing Address - Country:US
Mailing Address - Phone:205-414-4402
Mailing Address - Fax:205-414-4425
Practice Address - Street 1:3485 INDEPENDENCE DR
Practice Address - Street 2:
Practice Address - City:HOMEWOOD
Practice Address - State:AL
Practice Address - Zip Code:35209-5603
Practice Address - Country:US
Practice Address - Phone:205-414-4402
Practice Address - Fax:205-414-4425
Is Sole Proprietor?:No
Enumeration Date:2005-06-21
Last Update Date:2009-09-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL117872085R0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0001XAllopathic & Osteopathic PhysiciansRadiologyRadiation Oncology
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL0366100001OtherMC NSC
ALP00462711OtherRAILROAD MEDICARE PTAN
AL0366100001OtherCIGNA GOVERNMENT SERVICES PTAN
C76181Medicare UPIN
AL051558709Medicare PIN