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NPI Code Detail

MEDICARE: DR. DOUGLAS GLEN LARSON M.D.

MEDICARE: DR. DOUGLAS GLEN LARSON M.D.
Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

# Taxonomy Code Taxonomy License Number License Number State
12085R0202XDiagnostic Radiology Physician15305NV
22085R0202XDiagnostic Radiology PhysicianMD172183OR

Medicare Identifiers

# Provider Identifier Provider Identifier Type Provider Identifier State Provider Identifier Issuer
2P01418514OTHERNVRR MEDICARE DRS

Other Identifiers

# Provider Identifier Provider Identifier Type Provider Identifier State Provider Identifier Issuer
1MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
3P01352399OTHERNVRR DR

General Provider Information

NPI Number : 1003064999
Entity Type Code : Individual
Provider Name (Legal Business Name) : DR. DOUGLAS GLEN LARSON M.D.
Provider Business Mailing Address
First Line : 2020 PALOMINO LN
Second Line : #100
City : LAS VEGAS
State : NV
Zip : 89106-4842
Country : US
Telephone Number : 702-759-8600
Fax Number :
Provider Business Practice Location Address
First Line : 2020 PALOMINO LN
Second Line : #100
City : LAS VEGAS
State : NV
Zip : 89106-4842
Country : US
Telephone Number : 702-759-8600
Fax Number :
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 09/04/2008
Last Update Date : 10/03/2016

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