Provider Demographics
NPI:1386806917
Name:LARSON, JAY C (DPM)
Entity type:Individual
Prefix:
First Name:JAY
Middle Name:C
Last Name:LARSON
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5750 W THUNDERBIRD RD STE G700
Mailing Address - Street 2:
Mailing Address - City:GLENDALE
Mailing Address - State:AZ
Mailing Address - Zip Code:85306-4673
Mailing Address - Country:US
Mailing Address - Phone:602-938-3600
Mailing Address - Fax:602-938-0400
Practice Address - Street 1:5750 W THUNDERBIRD RD STE G700
Practice Address - Street 2:
Practice Address - City:GLENDALE
Practice Address - State:AZ
Practice Address - Zip Code:85306
Practice Address - Country:US
Practice Address - Phone:602-938-3600
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-06-25
Last Update Date:2021-07-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ0729213E00000X, 213ES0103X
MI5901002297213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle Surgery
No213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ618036Medicaid
AZZ146474Medicare PIN