Provider Demographics
NPI:1063512895
Name:LARSON, RICHARD LEE (MD)
Entity type:Individual
Prefix:
First Name:RICHARD
Middle Name:LEE
Last Name:LARSON
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:P.O. BOX 160
Mailing Address - Street 2:
Mailing Address - City:BELCOURT
Mailing Address - State:ND
Mailing Address - Zip Code:58316-0160
Mailing Address - Country:US
Mailing Address - Phone:701-477-6111
Mailing Address - Fax:701-477-2507
Practice Address - Street 1:1300 HOSPITAL LOOP
Practice Address - Street 2:
Practice Address - City:BELCOURT
Practice Address - State:ND
Practice Address - Zip Code:58316-0160
Practice Address - Country:US
Practice Address - Phone:701-477-6111
Practice Address - Fax:701-477-2507
Is Sole Proprietor?:No
Enumeration Date:2006-09-22
Last Update Date:2012-12-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NDND5215207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
ND01063Medicaid
350063Medicare PIN
D64970Medicare UPIN