Provider Demographics
NPI:1215932173
Name:LARSON, JOHN ROBERT (MD)
Entity type:Individual
Prefix:DR
First Name:JOHN
Middle Name:ROBERT
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 1:1724 W PLYMOUTH ST
Mailing Address - Street 2:
Mailing Address - City:BREMEN
Mailing Address - State:IN
Mailing Address - Zip Code:46506-1940
Mailing Address - Country:US
Mailing Address - Phone:574-546-3649
Mailing Address - Fax:574-546-3952
Practice Address - Street 1:1724 W PLYMOUTH ST
Practice Address - Street 2:
Practice Address - City:BREMEN
Practice Address - State:IN
Practice Address - Zip Code:46506-1940
Practice Address - Country:US
Practice Address - Phone:574-546-3649
Practice Address - Fax:574-546-3952
Is Sole Proprietor?:Yes
Enumeration Date:2005-06-16
Last Update Date:2010-01-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01033673207Q00000X, 207VX0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No207VX0000XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyObstetrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN100468970BMedicaid
IN371199381OtherTRICARE
IN000000296642OtherANTHEM BCBS
IN0004619574OtherAETNA
IN000000296642OtherANTHEM BCBS