Healthcare Provider Details

I. General information

NPI: 1336604297
Provider Name (Legal Business Name): CHARLES BAYARD LARCOM IV MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/05/2019
Last Update Date: 07/18/2025
Certification Date: 07/18/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9040 JACKSON AVE
TACOMA WA
98431
US

IV. Provider business mailing address

8901 WISCONSIN AVE
BETHESDA MD
20889-5600
US

V. Phone/Fax

Practice location:
  • Phone: 253-968-2462
  • Fax: 253-968-2972
Mailing address:
  • Phone: 12-954-1913
  • Fax: 301-319-8751

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number7491920
License Number StateWI
# 3
Primary TaxonomyN
Taxonomy Code207RC0200X
TaxonomyCritical Care Medicine (Internal Medicine) Physician
License Number7491920
License Number StateWI
# 4
Primary TaxonomyY
Taxonomy Code207RP1001X
TaxonomyPulmonary Disease Physician
License Number7491920
License Number StateWI
# 5
Primary TaxonomyN
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
License Number74919-20
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: