Provider Demographics
NPI:1336149483
Name:LARSON, THOMAS JENNINGS JR (DPM)
Entity Type:Individual
Prefix:
First Name:THOMAS
Middle Name:JENNINGS
Last Name:LARSON
Suffix:JR
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2821 S 87TH AVE
Mailing Address - Street 2:
Mailing Address - City:OMAHA
Mailing Address - State:NE
Mailing Address - Zip Code:68124-3046
Mailing Address - Country:US
Mailing Address - Phone:402-391-0960
Mailing Address - Fax:402-391-1463
Practice Address - Street 1:2821 S 87TH AVE
Practice Address - Street 2:
Practice Address - City:OMAHA
Practice Address - State:NE
Practice Address - Zip Code:68124-3046
Practice Address - Country:US
Practice Address - Phone:402-391-0960
Practice Address - Fax:402-391-1463
Is Sole Proprietor?:No
Enumeration Date:2005-07-29
Last Update Date:2008-02-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE157213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NET71378Medicare UPIN
NE4912550001Medicare NSC
NE091274Medicare PIN