Provider Demographics
NPI:1942200233
Name:LARSON, ROBERT DOUGLAS (DC)
Entity Type:Individual
Prefix:DR
First Name:ROBERT
Middle Name:DOUGLAS
Last Name:LARSON
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3241 E SHEA BLVD
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85028-3335
Mailing Address - Country:US
Mailing Address - Phone:602-996-3601
Mailing Address - Fax:602-996-0068
Practice Address - Street 1:3241 E SHEA BLVD
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85028-3335
Practice Address - Country:US
Practice Address - Phone:602-996-3601
Practice Address - Fax:602-996-0068
Is Sole Proprietor?:Yes
Enumeration Date:2005-07-28
Last Update Date:2007-07-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ5128111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZU05506Medicare UPIN