Provider Demographics
NPI:1891040440
Name:LARSEN, MICHAEL THORPE (MD)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:THORPE
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 1:370 E VIRGINIA AVE STE 100
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85004-1254
Mailing Address - Country:US
Mailing Address - Phone:602-258-4788
Mailing Address - Fax:
Practice Address - Street 1:370 E VIRGINIA AVE STE 100
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85004-1254
Practice Address - Country:US
Practice Address - Phone:614-293-8652
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-07-19
Last Update Date:2019-10-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHAO5603724206896208200000X
AZ588712086S0105X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2086S0105XAllopathic & Osteopathic PhysiciansSurgerySurgery of the Hand
No208200000XAllopathic & Osteopathic PhysiciansPlastic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ553192Medicaid