Provider Demographics
NPI:1861546673
Name:LARSEN, JERRY K (MD PC)
Entity type:Individual
Prefix:
First Name:JERRY
Middle Name:K
Last Name:LARSEN
Suffix:
Gender:M
Credentials:MD PC
Other - Prefix:
Other - First Name:
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Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:15255 SE RIVER FOREST DR
Mailing Address - Street 2:
Mailing Address - City:MILWAUKIE
Mailing Address - State:OR
Mailing Address - Zip Code:97267
Mailing Address - Country:US
Mailing Address - Phone:503-657-7235
Mailing Address - Fax:503-657-7676
Practice Address - Street 1:610 JEFFERSON ST
Practice Address - Street 2:WILLAMETTE VALLEY FAMILY CENTER
Practice Address - City:OREGON CITY
Practice Address - State:OR
Practice Address - Zip Code:97045
Practice Address - Country:US
Practice Address - Phone:503-657-7235
Practice Address - Fax:503-657-7676
Is Sole Proprietor?:No
Enumeration Date:2007-01-22
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
ORMD079042084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
L26967Medicare UPIN
104220Medicare ID - Type Unspecified