Provider Demographics
NPI:1780799437
Name:LARSON, HEIDI M (MD)
Entity type:Individual
Prefix:
First Name:HEIDI
Middle Name:M
Last Name:LARSON
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:161 CORPORATE DR
Mailing Address - Street 2:
Mailing Address - City:PORTSMOUTH
Mailing Address - State:NH
Mailing Address - Zip Code:03801-6825
Mailing Address - Country:US
Mailing Address - Phone:603-431-5154
Mailing Address - Fax:
Practice Address - Street 1:2 GREAT FALLS PLZ STE 21
Practice Address - Street 2:
Practice Address - City:AUBURN
Practice Address - State:ME
Practice Address - Zip Code:04210-5966
Practice Address - Country:US
Practice Address - Phone:207-330-3950
Practice Address - Fax:207-330-3955
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-21
Last Update Date:2020-06-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MEMD14388207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
ME046529OtherANTHEM
ME3 5150000Medicaid
ME5904624OtherAETNA
H07227Medicare UPIN