Provider Demographics
NPI:1588764385
Name:CARSON, LARRY VAN (MD)
Entity type:Individual
Prefix:
First Name:LARRY
Middle Name:VAN
Last Name:CARSON
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:PO BOX 9788
Mailing Address - Street 2:
Mailing Address - City:BELFAST
Mailing Address - State:ME
Mailing Address - Zip Code:04915-9788
Mailing Address - Country:US
Mailing Address - Phone:910-295-0215
Mailing Address - Fax:910-295-0218
Practice Address - Street 1:11104 PARKVIEW CIRCLE DR STE 110
Practice Address - Street 2:
Practice Address - City:FORT WAYNE
Practice Address - State:IN
Practice Address - Zip Code:46845-1673
Practice Address - Country:US
Practice Address - Phone:260-425-6780
Practice Address - Fax:260-425-6615
Is Sole Proprietor?:No
Enumeration Date:2006-09-22
Last Update Date:2024-12-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101039834207T00000X
GA20197207T00000X
NC2008-02090207T00000X
WV14284207T00000X
TN25835207T00000X
IN01082907A208200000X, 207T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207T00000XAllopathic & Osteopathic PhysiciansNeurological Surgery
No208200000XAllopathic & Osteopathic PhysiciansPlastic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC5911722Medicaid
WV0089635000Medicaid
WV0089635000Medicaid
NC2073296Medicare PIN
TN103I148455Medicare PIN