1083697635 NPI number — WILLIAM DAVID LARSON MD

Table of content: WILLIAM DAVID LARSON MD (NPI 1083697635)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1083697635 NPI number — WILLIAM DAVID LARSON MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
LARSON
Provider First Name:
WILLIAM
Provider Middle Name:
DAVID
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
MD
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
LARSON
Provider Other First Name:
W
Provider Other Middle Name:
DAVID
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
MD
Provider Other Last Name Type Code:
2

NPI Number Information

NPI Number:
1083697635
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
05/29/2013
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
6420 SW MACADAM AVE
Provider Second Line Business Mailing Address:
SUITE 216
Provider Business Mailing Address City Name:
PORTLAND
Provider Business Mailing Address State Name:
OR
Provider Business Mailing Address Postal Code:
97239-3507
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
503-244-8601
Provider Business Mailing Address Fax Number:
503-244-3013

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
19250 SW 65TH AVE
Provider Second Line Business Practice Location Address:
STE 215
Provider Business Practice Location Address City Name:
TUALATIN
Provider Business Practice Location Address State Name:
OR
Provider Business Practice Location Address Postal Code:
97062-7452
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
503-692-3630
Provider Business Practice Location Address Fax Number:
503-692-3420
Provider Enumeration Date:
11/28/2005

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 207W00000X , with the licence number:  MD10715 , registered in the state of OR ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 060087 , issued by the state of ( OR ) . This identifiers is of the category "MEDICAID".
  • Identifier: 180002095 . This is a "RAILROAD MEDICARE" identifier , issued by the state of ( OR ) . This identifiers is of the category "OTHER".




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