MEDICARE: DR. JON LARSON M.D.

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	208100000X	Physical Medicine & Rehabilitation Physician	10339	AZ

General Provider Information

NPI Number	:	1629049473
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. JON LARSON M.D.

Provider Business Mailing Address
First Line	:	2102 N COUNTRY CLUB RD
Second Line	:	BLDG B
City	:	TUCSON
State	:	AZ
Zip	:	85716-2831
Country	:	US
Telephone Number	:	520-795-8371
Fax Number	:

Provider Business Practice Location Address
First Line	:	2102 N COUNTRY CLUB RD
Second Line	:	BLDG B
City	:	TUCSON
State	:	AZ
Zip	:	85716-2831
Country	:	US
Telephone Number	:	520-795-8371
Fax Number	:

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

Provider Enumeration Date	:	01/30/2006
Last Update Date	:	07/08/2007

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