Provider Demographics
NPI:1730125402
Name:LARSON, LAWRENCE O (MD)
Entity type:Individual
Prefix:
First Name:LAWRENCE
Middle Name:O
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 1:541 OTIS BOWEN DR
Mailing Address - Street 2:
Mailing Address - City:MUNSTER
Mailing Address - State:IN
Mailing Address - Zip Code:46321-4158
Mailing Address - Country:US
Mailing Address - Phone:219-934-5300
Mailing Address - Fax:
Practice Address - Street 1:1907 W SYCAMORE
Practice Address - Street 2:
Practice Address - City:KOKOMO
Practice Address - State:IN
Practice Address - Zip Code:46901
Practice Address - Country:US
Practice Address - Phone:765-449-2732
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-06-21
Last Update Date:2008-03-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01046176207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN815140QMedicare PIN