Healthcare Provider Details

I. General information

NPI: 1952104978
Provider Name (Legal Business Name): THEODORE ROBERT LARSEN
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/27/2025
Last Update Date: 03/26/2026
Certification Date: 03/26/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2001 W 86TH ST
INDIANAPOLIS IN
46260-1902
US

IV. Provider business mailing address

3200 COLD SPRING RD
INDIANAPOLIS IN
46222-1960
US

V. Phone/Fax

Practice location:
  • Phone: 317-338-6399
  • Fax: 317-231-5405
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: