Provider Demographics
NPI:1285998146
Name:LARSEN, THOMAS (MD)
Entity type:Individual
Prefix:
First Name:THOMAS
Middle Name:
Last Name:LARSEN
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 1:4440 PORTAGE AVE
Mailing Address - Street 2:
Mailing Address - City:SOUTH BEND
Mailing Address - State:IN
Mailing Address - Zip Code:46628-9570
Mailing Address - Country:US
Mailing Address - Phone:574-204-6200
Mailing Address - Fax:574-239-1520
Practice Address - Street 1:4440 PORTAGE AVE
Practice Address - Street 2:
Practice Address - City:SOUTH BEND
Practice Address - State:IN
Practice Address - Zip Code:46628-9570
Practice Address - Country:US
Practice Address - Phone:574-204-6200
Practice Address - Fax:574-239-1520
Is Sole Proprietor?:No
Enumeration Date:2012-06-26
Last Update Date:2015-09-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01075173A207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN201112870Medicaid
IN201112870Medicaid