Provider Demographics
NPI:1548366891
Name:LARSON, JEREMY TODD (MD)
Entity type:Individual
Prefix:
First Name:JEREMY
Middle Name:TODD
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 1:1818 E REZANOF DR
Mailing Address - Street 2:
Mailing Address - City:KODIAK
Mailing Address - State:AK
Mailing Address - Zip Code:99615
Mailing Address - Country:US
Mailing Address - Phone:907-486-6065
Mailing Address - Fax:907-486-2248
Practice Address - Street 1:1818 E REZANOF DR
Practice Address - Street 2:
Practice Address - City:KODIAK
Practice Address - State:AK
Practice Address - Zip Code:99615
Practice Address - Country:US
Practice Address - Phone:907-486-6065
Practice Address - Fax:907-486-2248
Is Sole Proprietor?:No
Enumeration Date:2006-09-15
Last Update Date:2009-10-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AK4934207Q00000X
WA44523207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA8419657Medicaid
WA8419657Medicaid