MEDICARE: WILLIAM DAVID LARSON IDC

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	1710I1002X	Independent Duty Corpsman

General Provider Information

NPI Number	:	1952555922
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	WILLIAM DAVID LARSON IDC

Provider Business Mailing Address
First Line	:	350 SOUTH CRAG RD.
Second Line	:
City	:	PANAMA CITY
State	:	FL
Zip	:	32407
Country	:	US
Telephone Number	:	850-235-5218
Fax Number	:

Provider Business Practice Location Address
First Line	:	350 SOUTH CRAG RD.
Second Line	:
City	:	PANAMA CITY
State	:	FL
Zip	:	32407-7013
Country	:	US
Telephone Number	:	850-235-5218
Fax Number	:

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

Provider Enumeration Date	:	11/04/2008
Last Update Date	:	11/04/2008

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