Provider Demographics
NPI:1134188394
Name:L CRAIG LARSEN DPM PC
Entity type:Organization
Organization Name:L CRAIG LARSEN DPM PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:L
Authorized Official - Middle Name:CLARK
Authorized Official - Last Name:LARSEN
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:801-261-1391
Mailing Address - Street 1:5801 FASHION BLVD
Mailing Address - Street 2:# 120
Mailing Address - City:MURRAY
Mailing Address - State:UT
Mailing Address - Zip Code:84107-6159
Mailing Address - Country:US
Mailing Address - Phone:801-261-1391
Mailing Address - Fax:801-261-1394
Practice Address - Street 1:5801 FASHION BLVD
Practice Address - Street 2:# 120
Practice Address - City:MURRAY
Practice Address - State:UT
Practice Address - Zip Code:84107-6159
Practice Address - Country:US
Practice Address - Phone:801-261-1391
Practice Address - Fax:801-261-1394
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-03-17
Last Update Date:2014-12-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT101447-0501213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT529501253006Medicaid
UT529501253006Medicaid
UTT48853Medicare UPIN
UT0578030001Medicare NSC