Healthcare Provider Details

I. General information

NPI: 1801162789
Provider Name (Legal Business Name): GABRIEL LARSON MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/26/2012
Last Update Date: 03/17/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

700 S.W. CAMPUS DRIVE, 7TH FLOOR
PORTLAND OR
97239
US

IV. Provider business mailing address

700 S.W. CAMPUS DRIVE, 7TH FLOOR
PORTLAND OR
97239
US

V. Phone/Fax

Practice location:
  • Phone: 503-418-5700
  • Fax: 503-418-5704
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberA120054
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberMD186278
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: