Healthcare Provider Details

I. General information

NPI: 1497778054
Provider Name (Legal Business Name): LARRY DOUGLAS VAN FOSSEN D.O.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/25/2006
Last Update Date: 03/28/2023
Certification Date: 03/28/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5955 RAND BLVD
SARASOTA FL
34238-5160
US

IV. Provider business mailing address

5955 RAND BLVD
SARASOTA FL
34238-5160
US

V. Phone/Fax

Practice location:
  • Phone: 941-893-6620
  • Fax: 941-748-8440
Mailing address:
  • Phone: 941-893-6620
  • Fax: 941-748-8440

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207LH0002X
TaxonomyHospice and Palliative Medicine (Anesthesiology) Physician
License Number34.005429
License Number StateOH
# 2
Primary TaxonomyY
Taxonomy Code207L00000X
TaxonomyAnesthesiology Physician
License NumberOS18532
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: