Provider Demographics
NPI:1902908296
Name:LARSON, EDWIN R (MD)
Entity Type:Individual
Prefix:DR
First Name:EDWIN
Middle Name:R
Last Name:LARSON
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
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Mailing Address - Street 1:2033 WOOD ST
Mailing Address - Street 2:STE 220
Mailing Address - City:SARASOTA
Mailing Address - State:FL
Mailing Address - Zip Code:34237-7900
Mailing Address - Country:US
Mailing Address - Phone:941-677-3366
Mailing Address - Fax:941-677-3367
Practice Address - Street 1:2033 WOOD ST
Practice Address - Street 2:STE 220
Practice Address - City:SARASOTA
Practice Address - State:FL
Practice Address - Zip Code:34237-7900
Practice Address - Country:US
Practice Address - Phone:941-677-3366
Practice Address - Fax:941-677-3367
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-05
Last Update Date:2014-01-08
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
OH35-04-1086101YM0800X
FLME1073122084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0446063OtherMEDICARE P-CAN