Provider Demographics
NPI:1801162789
Name:LARSON, GABRIEL (MD)
Entity type:Individual
Prefix:
First Name:GABRIEL
Middle Name:
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 1:700 S.W. CAMPUS DRIVE, 7TH FLOOR
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97239
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:700 S.W. CAMPUS DRIVE, 7TH FLOOR
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97239
Practice Address - Country:US
Practice Address - Phone:503-418-5700
Practice Address - Fax:503-418-5704
Is Sole Proprietor?:No
Enumeration Date:2012-03-26
Last Update Date:2018-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA120054208000000X
ORMD186278208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics