Provider Demographics
NPI:1902068497
Name:LARSON, DANIEL A (MD)
Entity Type:Individual
Prefix:DR
First Name:DANIEL
Middle Name:A
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 1:1222 S PATTERSON BLVD
Mailing Address - Street 2:STE 400
Mailing Address - City:DAYTON
Mailing Address - State:OH
Mailing Address - Zip Code:45402-2642
Mailing Address - Country:US
Mailing Address - Phone:228-376-0420
Mailing Address - Fax:
Practice Address - Street 1:1222 S PATTERSON BLVD
Practice Address - Street 2:SUITE 400
Practice Address - City:DAYTON
Practice Address - State:OH
Practice Address - Zip Code:45402-2684
Practice Address - Country:US
Practice Address - Phone:937-496-2620
Practice Address - Fax:937-496-2610
Is Sole Proprietor?:No
Enumeration Date:2008-06-26
Last Update Date:2021-02-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35-130667207Y00000X
PAMD445563207Y00000X
VA0011619845390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Y00000XAllopathic & Osteopathic PhysiciansOtolaryngology
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0236207Medicaid
OHH584930OtherMEDICARE