Provider Demographics
NPI:1427057439
Name:MATHISON, LARRY A (MD)
Entity type:Individual
Prefix:
First Name:LARRY
Middle Name:A
Last Name:MATHISON
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 1:2200 COMMERCE BLVD
Mailing Address - Street 2:
Mailing Address - City:MOUND
Mailing Address - State:MN
Mailing Address - Zip Code:55364-1547
Mailing Address - Country:US
Mailing Address - Phone:952-495-2000
Mailing Address - Fax:952-495-2060
Practice Address - Street 1:2200 COMMERCE BLVD
Practice Address - Street 2:
Practice Address - City:MOUND
Practice Address - State:MN
Practice Address - Zip Code:55364-1547
Practice Address - Country:US
Practice Address - Phone:952-495-2000
Practice Address - Fax:952-495-2060
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-07-20
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN19846207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
19846OtherMEDICAL LICENSE
19846OtherMEDICAL LICENSE