Healthcare Provider Details

I. General information

NPI: 1386806917
Provider Name (Legal Business Name): JAY C LARSON DPM
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/25/2008
Last Update Date: 07/20/2021
Certification Date: 07/20/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5750 W THUNDERBIRD RD STE G700
GLENDALE AZ
85306
US

IV. Provider business mailing address

5750 W THUNDERBIRD RD STE G700
GLENDALE AZ
85306-4673
US

V. Phone/Fax

Practice location:
  • Phone: 602-938-3600
  • Fax:
Mailing address:
  • Phone: 602-938-3600
  • Fax: 602-938-0400

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code213E00000X
TaxonomyPodiatrist
License Number0729
License Number StateAZ
# 2
Primary TaxonomyN
Taxonomy Code213E00000X
TaxonomyPodiatrist
License Number5901002297
License Number StateMI
# 3
Primary TaxonomyY
Taxonomy Code213ES0103X
TaxonomyFoot & Ankle Surgery Podiatrist
License Number0729
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: