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General NPI Number Information
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NPI Number | 1578663969
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Entity Type | Individual
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Provider Name | THEODORE CARL LARSON III M.D.
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Gender | Male
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Dates
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Enumeration Date | 09/25/2006
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Last Update Date | 07/05/2018
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Provider Practice Location Address
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Address Line | 11750 W 2ND PL SUITE 255
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City | LAKEWOOD
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State | CO
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Zip | 80228
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Country | US
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Telephone | 720-321-8040
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Fax | 720-321-8041
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Provider Business Mailing Address
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Address Line | 11750 W 2ND PL STE 255
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City | LAKEWOOD
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State | CO
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Zip | 80228-1726
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Country | US
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Telephone | 720-321-8040
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Fax | 720-321-8041
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 2085N0700X
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Taxonomy Name | Neuroradiology Physician
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License Number | 44928
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License Number State | CO
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