Provider Demographics
NPI:1427046770
Name:LARSEN, ROBERT WAYNE (DPM)
Entity type:Individual
Prefix:
First Name:ROBERT
Middle Name:WAYNE
Last Name:LARSEN
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 1:1600 CREEKSIDE DR
Mailing Address - Street 2:STE 3100
Mailing Address - City:FOLSOM
Mailing Address - State:CA
Mailing Address - Zip Code:95630-3444
Mailing Address - Country:US
Mailing Address - Phone:916-983-8555
Mailing Address - Fax:916-983-8568
Practice Address - Street 1:1600 CREEKSIDE DR
Practice Address - Street 2:STE 3100
Practice Address - City:FOLSOM
Practice Address - State:CA
Practice Address - Zip Code:95630-3444
Practice Address - Country:US
Practice Address - Phone:916-983-8555
Practice Address - Fax:916-983-8568
Is Sole Proprietor?:Yes
Enumeration Date:2005-10-11
Last Update Date:2012-09-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAE2687213ES0103X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA000E26870Medicaid
318089200OtherDEPT OF LABOR
CA000E26872Medicaid
480017653OtherRAILROAD MEDICARE
318089200OtherDEPT OF LABOR
000E2687Medicare ID - Type Unspecified
T11441Medicare UPIN