Healthcare Provider Details

I. General information

NPI: 1427057439
Provider Name (Legal Business Name): LARRY A MATHISON MD
Entity Type: Individual
Gender: Male
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 07/20/2005
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2200 COMMERCE BLVD
MOUND MN
55364-1547
US

IV. Provider business mailing address

2200 COMMERCE BLVD
MOUND MN
55364-1547
US

V. Phone/Fax

Practice location:
  • Phone: 952-495-2000
  • Fax: 952-495-2060
Mailing address:
  • Phone: 952-495-2000
  • Fax: 952-495-2060

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number19846
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: