Provider Demographics
NPI:1386735256
Name:LARSON, SUSAN GAYLE (MD)
Entity type:Individual
Prefix:DR
First Name:SUSAN
Middle Name:GAYLE
Last Name:LARSON
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1120 AUGUST DR
Mailing Address - Street 2:
Mailing Address - City:ANNAPOLIS
Mailing Address - State:MD
Mailing Address - Zip Code:21403-4613
Mailing Address - Country:US
Mailing Address - Phone:410-268-0036
Mailing Address - Fax:
Practice Address - Street 1:3300 GAITHER RD
Practice Address - Street 2:
Practice Address - City:BALTIMORE
Practice Address - State:MD
Practice Address - Zip Code:21244-2916
Practice Address - Country:US
Practice Address - Phone:410-922-2100
Practice Address - Fax:410-496-5620
Is Sole Proprietor?:No
Enumeration Date:2006-09-27
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDD00503062084P0804X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0804XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyChild & Adolescent Psychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
MDG56857Medicare UPIN