Healthcare Provider Details

I. General information

NPI: 1366532913
Provider Name (Legal Business Name): ROBERT LARSON D.P.M.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/13/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4701 N. LAS VEGAS BLVD.
N. LAS VEGAS NV
89191
US

IV. Provider business mailing address

7245 W LA MADRE WAY
LAS VEGAS NV
89149-5858
US

V. Phone/Fax

Practice location:
  • Phone: 702-653-3134
  • Fax: 702-653-2790
Mailing address:
  • Phone: 702-653-3134
  • Fax: 702-653-2790

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code213ES0103X
TaxonomyFoot & Ankle Surgery Podiatrist
License NumberNV9604
License Number StateNV
# 2
Primary TaxonomyN
Taxonomy Code213ES0103X
TaxonomyFoot & Ankle Surgery Podiatrist
License Number9604
License Number StateNV

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: