Provider Demographics
NPI:1962507210
Name:LARSON, JOHN (MD)
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:
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:PO BOX 4925
Mailing Address - Street 2:
Mailing Address - City:DES MOINES
Mailing Address - State:IA
Mailing Address - Zip Code:50305-4925
Mailing Address - Country:US
Mailing Address - Phone:515-271-6300
Mailing Address - Fax:515-271-6311
Practice Address - Street 1:1750 48TH ST
Practice Address - Street 2:SUITE 2
Practice Address - City:DES MOINES
Practice Address - State:IA
Practice Address - Zip Code:50310-1988
Practice Address - Country:US
Practice Address - Phone:515-271-6300
Practice Address - Fax:515-271-6311
Is Sole Proprietor?:No
Enumeration Date:2006-09-13
Last Update Date:2010-02-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA181742084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA4134023Medicaid
IA21690OtherWELLMARK
IA4134023Medicaid
IAI11394Medicare ID - Type Unspecified