Provider Demographics
NPI:1881617488
Name:LARSON, ROBERT (MD)
Entity type:Individual
Prefix:
First Name:ROBERT
Middle Name:
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 1:605 WELCH ST
Mailing Address - Street 2:
Mailing Address - City:SILVERTON
Mailing Address - State:OR
Mailing Address - Zip Code:97381-1946
Mailing Address - Country:US
Mailing Address - Phone:503-873-6907
Mailing Address - Fax:503-873-8923
Practice Address - Street 1:26004 104TH AVE SE
Practice Address - Street 2:
Practice Address - City:KENT
Practice Address - State:WA
Practice Address - Zip Code:98030-7677
Practice Address - Country:US
Practice Address - Phone:425-251-4040
Practice Address - Fax:877-514-9952
Is Sole Proprietor?:No
Enumeration Date:2006-07-25
Last Update Date:2024-10-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORMD17821207Q00000X
WAMD61360488207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR045166Medicaid
ORF32446Medicare UPIN
OR00WFBRNBMedicare PIN