Provider Demographics
NPI:1740288927
Name:LARSON, DAVID E (MSPT)
Entity type:Individual
Prefix:MR
First Name:DAVID
Middle Name:E
Last Name:LARSON
Suffix:
Gender:M
Credentials:MSPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10 LIBERTY SQ # B-1
Mailing Address - Street 2:
Mailing Address - City:BOSTON
Mailing Address - State:MA
Mailing Address - Zip Code:02109-5801
Mailing Address - Country:US
Mailing Address - Phone:617-536-1161
Mailing Address - Fax:617-536-1165
Practice Address - Street 1:63 MELCHER ST STE 100
Practice Address - Street 2:
Practice Address - City:BOSTON
Practice Address - State:MA
Practice Address - Zip Code:02210-1534
Practice Address - Country:US
Practice Address - Phone:617-536-1161
Practice Address - Fax:617-536-1165
Is Sole Proprietor?:No
Enumeration Date:2005-07-12
Last Update Date:2022-01-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA12053225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MAAA 27096OtherHARVARD PILGRIM GROUP #
MAY67685OtherBC/BS PROVIDER NUMBER
MALA Y68280Medicare ID - Type UnspecifiedPHYSICAL THERAPY PROVIDER