MEDICARE: DR. JOHN W LARGEN JR. PHD

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	103G00000X	Clinical Neuropsychologist	22321	TX

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	86691A	OTHER	TX	BCBS
2	5194361	OTHER		AETNA PPO PRODUCTS

General Provider Information

NPI Number	:	1265425466
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. JOHN W LARGEN JR. PHD

Provider Business Mailing Address
First Line	:	1020 HOLCOMBE BLVD
Second Line	:	STE 1304
City	:	HOUSTON
State	:	TX
Zip	:	77030-2210
Country	:	US
Telephone Number	:	713-799-2818
Fax Number	:	713-790-1454

Provider Business Practice Location Address
First Line	:	1020 HOLCOMBE BLVD
Second Line	:	STE 1304
City	:	HOUSTON
State	:	TX
Zip	:	77030-2210
Country	:	US
Telephone Number	:	713-799-2818
Fax Number	:	713-790-1454

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	08/24/2005
Last Update Date	:	08/28/2007

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