Healthcare Provider Details

I. General information

NPI: 1881617488
Provider Name (Legal Business Name): ROBERT LARSON M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/25/2006
Last Update Date: 10/11/2024
Certification Date: 10/11/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

26004 104TH AVE SE
KENT WA
98030-7677
US

IV. Provider business mailing address

605 WELCH ST
SILVERTON OR
97381-1946
US

V. Phone/Fax

Practice location:
  • Phone: 425-251-4040
  • Fax: 877-514-9952
Mailing address:
  • Phone: 503-873-6907
  • Fax: 503-873-8923

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberMD17821
License Number StateOR
# 2
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberMD61360488
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: