Provider Demographics
NPI:1861656332
Name:LARSEN, CLINT (DPM)
Entity Type:Individual
Prefix:
First Name:CLINT
Middle Name:
Last Name:LARSEN
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:837 E. CEDAR ST
Mailing Address - Street 2:SUITE 100
Mailing Address - City:SOUTH BEND
Mailing Address - State:IN
Mailing Address - Zip Code:46617
Mailing Address - Country:US
Mailing Address - Phone:574-237-7338
Mailing Address - Fax:574-237-7881
Practice Address - Street 1:5801 S FASHION BLVD
Practice Address - Street 2:STE 120
Practice Address - City:MURRAY
Practice Address - State:UT
Practice Address - Zip Code:84107-8115
Practice Address - Country:US
Practice Address - Phone:801-261-1391
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-07-15
Last Update Date:2016-01-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN41000220213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist