Provider Demographics
NPI:1972561165
Name:LARSEN, BRYAN R (MD)
Entity Type:Individual
Prefix:DR
First Name:BRYAN
Middle Name:R
Last Name:LARSEN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:630 E 1400 N
Mailing Address - Street 2:SUITE 100B
Mailing Address - City:LOGAN
Mailing Address - State:UT
Mailing Address - Zip Code:84341-2534
Mailing Address - Country:US
Mailing Address - Phone:435-787-0270
Mailing Address - Fax:435-787-0262
Practice Address - Street 1:630 E 1400 N
Practice Address - Street 2:SUITE 100B
Practice Address - City:LOGAN
Practice Address - State:UT
Practice Address - Zip Code:84341-2534
Practice Address - Country:US
Practice Address - Phone:435-787-0270
Practice Address - Fax:435-787-0262
Is Sole Proprietor?:No
Enumeration Date:2006-05-04
Last Update Date:2021-09-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT174573-1205207RG0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterology
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID003794300Medicaid
ID003794300Medicaid
005566802Medicare ID - Type Unspecified