Provider Demographics
NPI:1841297405
Name:LARSON, ERNEST L (MD)
Entity type:Individual
Prefix:
First Name:ERNEST
Middle Name:L
Last Name:LARSON
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 1:265 S PARKSIDE DR
Mailing Address - Street 2:STE 100
Mailing Address - City:COLORADO SPRINGS
Mailing Address - State:CO
Mailing Address - Zip Code:80910-3141
Mailing Address - Country:US
Mailing Address - Phone:719-633-8773
Mailing Address - Fax:719-633-1905
Practice Address - Street 1:265 S PARKSIDE DR
Practice Address - Street 2:STE 100
Practice Address - City:COLORADO SPRINGS
Practice Address - State:CO
Practice Address - Zip Code:80910-3141
Practice Address - Country:US
Practice Address - Phone:719-633-8773
Practice Address - Fax:719-633-1905
Is Sole Proprietor?:No
Enumeration Date:2005-06-28
Last Update Date:2014-02-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO20212207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO01202126Medicaid
COC811575Medicare PIN
COCOAAA3755Medicare PIN
CO01202126Medicaid