Provider Demographics
NPI:1215165584
Name:LARSEN, STEPHEN (MD)
Entity type:Individual
Prefix:
First Name:STEPHEN
Middle Name:
Last Name:LARSEN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:17560 N 75TH AVE
Mailing Address - Street 2:SUITE 440
Mailing Address - City:GLENDALE
Mailing Address - State:AZ
Mailing Address - Zip Code:85308-5983
Mailing Address - Country:US
Mailing Address - Phone:623-512-4390
Mailing Address - Fax:623-512-4139
Practice Address - Street 1:13555 W MCDOWELL RD
Practice Address - Street 2:302
Practice Address - City:GOODYEAR
Practice Address - State:AZ
Practice Address - Zip Code:85395-2624
Practice Address - Country:US
Practice Address - Phone:623-512-4390
Practice Address - Fax:623-512-4391
Is Sole Proprietor?:No
Enumeration Date:2009-06-25
Last Update Date:2017-01-18
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
IL125-056789208800000X
AZ50775208800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208800000XAllopathic & Osteopathic PhysiciansUrology
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ053337Medicaid