Provider Demographics
NPI:1982670162
Name:LARSEN, WALTER G (MD)
Entity Type:Individual
Prefix:
First Name:WALTER
Middle Name:G
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 1:1414 NW NORTHRUP ST
Mailing Address - Street 2:SUITE 600
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97209-2798
Mailing Address - Country:US
Mailing Address - Phone:503-223-3104
Mailing Address - Fax:503-223-4619
Practice Address - Street 1:1414 NW NORTHRUP ST
Practice Address - Street 2:SUITE 600
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97209-2798
Practice Address - Country:US
Practice Address - Phone:503-223-3104
Practice Address - Fax:503-223-4619
Is Sole Proprietor?:No
Enumeration Date:2006-02-27
Last Update Date:2010-07-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OROR 6013174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
ORC93111Medicare UPIN
OR100478Medicare ID - Type Unspecified