Healthcare Provider Details

I. General information

NPI: 1780799437
Provider Name (Legal Business Name): HEIDI M LARSON MD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/21/2006
Last Update Date: 06/11/2020
Certification Date: 06/11/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2 GREAT FALLS PLZ STE 21
AUBURN ME
04210-5966
US

IV. Provider business mailing address

161 CORPORATE DR
PORTSMOUTH NH
03801-6825
US

V. Phone/Fax

Practice location:
  • Phone: 207-330-3950
  • Fax: 207-330-3955
Mailing address:
  • Phone: 603-431-5154
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberMD14388
License Number StateME

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: