Healthcare Provider Details

I. General information

NPI: 1255991428
Provider Name (Legal Business Name): ROBERT CHARLES LARSEN MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/19/2019
Last Update Date: 11/27/2023
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7 PAINTBRUSH CIR
SANTA FE NM
87506-9539
US

IV. Provider business mailing address

7 PAINTBRUSH CIR
SANTA FE NM
87506-9539
US

V. Phone/Fax

Practice location:
  • Phone: 505-780-5727
  • Fax:
Mailing address:
  • Phone: 505-780-5727
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License NumberMD2017-0686
License Number StateNM
# 2
Primary TaxonomyY
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License NumberG39941
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: