Healthcare Provider Details

I. General information

NPI: 1275518631
Provider Name (Legal Business Name): BARRY J LARSON M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/08/2005
Last Update Date: 05/21/2024
Certification Date: 05/21/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3433 BROADWAY STREET NE SUITE 300
MINNEAPOLIS MN
55413-1761
US

IV. Provider business mailing address

3433 BROADWAY STREET NE SUITE 300
MINNEAPOLIS MN
55413-1761
US

V. Phone/Fax

Practice location:
  • Phone: 763-587-7737
  • Fax: 763-587-7069
Mailing address:
  • Phone: 763-587-7737
  • Fax: 763-587-7989

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number30136
License Number StateMN
# 2
Primary TaxonomyY
Taxonomy Code207QG0300X
TaxonomyGeriatric Medicine (Family Medicine) Physician
License Number30136
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: