Healthcare Provider Details

I. General information

NPI: 1831321546
Provider Name (Legal Business Name): JEREMY T LARSEN MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/13/2009
Last Update Date: 01/04/2024
Certification Date: 01/04/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

14200 W CELEBRATE LIFE WAY
GOODYEAR AZ
85338-3007
US

IV. Provider business mailing address

14200 W CELEBRATE LIFE WAY
GOODYEAR AZ
85338-3007
US

V. Phone/Fax

Practice location:
  • Phone: 623-207-3000
  • Fax: 623-207-3921
Mailing address:
  • Phone: 623-207-3000
  • Fax: 623-207-3921

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number53065
License Number StateMN
# 2
Primary TaxonomyY
Taxonomy Code207RH0003X
TaxonomyHematology & Oncology Physician
License Number54266
License Number StateAZ
# 3
Primary TaxonomyN
Taxonomy Code207RH0003X
TaxonomyHematology & Oncology Physician
License Number29227
License Number StateNE
# 4
Primary TaxonomyN
Taxonomy Code207RH0003X
TaxonomyHematology & Oncology Physician
License Number53065
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: