Provider Demographics
NPI:1992757991
Name:LARSON, SCOTT ALAN (MD)
Entity type:Individual
Prefix:DR
First Name:SCOTT
Middle Name:ALAN
Last Name:LARSON
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 1:190 E BANNOCK ST
Mailing Address - Street 2:
Mailing Address - City:BOISE
Mailing Address - State:ID
Mailing Address - Zip Code:83712-6241
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:305 E JEFFERSON ST
Practice Address - Street 2:
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83712-6231
Practice Address - Country:US
Practice Address - Phone:208-381-7370
Practice Address - Fax:208-381-6911
Is Sole Proprietor?:No
Enumeration Date:2006-05-17
Last Update Date:2024-10-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA34581207W00000X
UT52876571205207W00000X
ID8961062207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT120085200Medicaid
UT12463OtherU HEALTH PLANS
UTTPRA07668OtherMOLINA TIN 876151902
UT100501869Medicaid
UT1119924Medicaid
UT806733700Medicaid
UTD8294Medicaid
UT214773OtherALTIUS 876151902
UT52876571200001OtherBCBS TIN 876151902
UT73587OtherPEHP TIN 876151902
UT756072OtherDMBA TIN 876151902
UT0079679Medicaid
UT107018826102OtherIHC TIN 876151902
UT870638577TTLOtherEMIA TIN 876151902
UT120085200Medicaid
UT806733700Medicaid
UT100501869Medicaid