Provider Demographics
NPI:1528512175
Name:LARSON, ADAM SIGURD (IDC)
Entity type:Individual
Prefix:MR
First Name:ADAM
Middle Name:SIGURD
Last Name:LARSON
Suffix:
Gender:M
Credentials:IDC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:158 HAWTHORNE DR
Mailing Address - Street 2:17D
Mailing Address - City:NEW LONDON
Mailing Address - State:CT
Mailing Address - Zip Code:06320-4007
Mailing Address - Country:US
Mailing Address - Phone:920-562-0770
Mailing Address - Fax:
Practice Address - Street 1:158 HAWTHORNE DR
Practice Address - Street 2:17D
Practice Address - City:NEW LONDON
Practice Address - State:CT
Practice Address - Zip Code:06320-4007
Practice Address - Country:US
Practice Address - Phone:920-562-0770
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-08-12
Last Update Date:2016-08-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1710I1002XOther Service ProvidersMilitary Health Care ProviderIndependent Duty Corpsman