MEDICARE: DR. SUSAN A 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
1	208000000X	Pediatrics Physician	38667	CO

Other Identifiers

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

General Provider Information

NPI Number	:	1336125632
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. SUSAN A LARSON M.D.

Provider Business Mailing Address
First Line	:	4745 ARAPAHOE AVE
Second Line	:	STE 200
City	:	BOULDER
State	:	CO
Zip	:	80303-1080
Country	:	US
Telephone Number	:	303-938-4750
Fax Number	:	303-938-4753

Provider Business Practice Location Address
First Line	:	4745 ARAPAHOE AVE STE 200
Second Line	:
City	:	BOULDER
State	:	CO
Zip	:	80303-1082
Country	:	US
Telephone Number	:	303-938-4750
Fax Number	:	303-938-4753

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	12/19/2005
Last Update Date	:	03/22/2021

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