Healthcare Provider Details

I. General information

NPI: 1083697635
Provider Name (Legal Business Name): WILLIAM DAVID LARSON MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

Provider Other Name: W DAVID LARSON MD

II. Dates (important events)

Enumeration Date: 11/28/2005
Last Update Date: 05/29/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

19250 SW 65TH AVE STE 215
TUALATIN OR
97062-7452
US

IV. Provider business mailing address

6420 SW MACADAM AVE SUITE 216
PORTLAND OR
97239-3507
US

V. Phone/Fax

Practice location:
  • Phone: 503-692-3630
  • Fax: 503-692-3420
Mailing address:
  • Phone: 503-244-8601
  • Fax: 503-244-3013

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207W00000X
TaxonomyOphthalmology Physician
License NumberMD10715
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: