Healthcare Provider Details

I. General information

NPI: 1952810558
Provider Name (Legal Business Name): PAUL LARSON RICHARD DO
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/26/2017
Last Update Date: 07/21/2022
Certification Date: 07/27/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4371 NARROW LANE RD STE 100
MONTGOMERY AL
36116-2975
US

IV. Provider business mailing address

4371 NARROW LANE RD STE 100
MONTGOMERY AL
36116-2975
US

V. Phone/Fax

Practice location:
  • Phone: 334-613-3680
  • Fax: 334-613-3685
Mailing address:
  • Phone: 334-613-3680
  • Fax: 334-613-3685

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberDO.2152
License Number StateAL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: