Healthcare Provider Details

I. General information

NPI: 1518960087
Provider Name (Legal Business Name): MICHAEL J LARSON MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/27/2005
Last Update Date: 12/14/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

360 EAST MAIN
REXBURG ID
83440
US

IV. Provider business mailing address

360 EAST MAIN
REXBURG ID
83440
US

V. Phone/Fax

Practice location:
  • Phone: 208-356-9550
  • Fax: 208-356-8023
Mailing address:
  • Phone: 208-356-9550
  • Fax: 208-356-8023

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207X00000X
TaxonomyOrthopaedic Surgery Physician
License NumberM-5158
License Number StateID
# 2
Primary TaxonomyY
Taxonomy Code207X00000X
TaxonomyOrthopaedic Surgery Physician
License NumberM5158
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: