MEDICARE: GARY L 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	2085R0001X	Radiation Oncology Physician	13856	OK

Medicare Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
2	300042703	OTHER		RAILROAD MEDICARE

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	:	1578599304
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	GARY L LARSON M.D.

Provider Business Mailing Address
First Line	:	PO BOX 248856
Second Line	:
City	:	OKLAHOMA CITY
State	:	OK
Zip	:	73124-8856
Country	:	US
Telephone Number	:	405-607-4520
Fax Number	:	405-607-4525

Provider Business Practice Location Address
First Line	:	5911 W MEMORIAL RD
Second Line	:
City	:	OKLAHOMA CITY
State	:	OK
Zip	:	73142-2015
Country	:	US
Telephone Number	:	405-773-6530
Fax Number	:

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

Provider Enumeration Date	:	06/23/2006
Last Update Date	:	05/21/2024

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