Basic Information
| Provider Information | |||||||||
| NPI: | 1033206941 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | LARSON | ||||||||
| FirstName: | JEAN | ||||||||
| MiddleName: | M | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 43 WHITING HILL RD STE 300 | ||||||||
| Address2: | |||||||||
| City: | BREWER | ||||||||
| State: | ME | ||||||||
| PostalCode: | 044121006 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2079735042 | ||||||||
| FaxNumber: | 2079735042 | ||||||||
| Practice Location | |||||||||
| Address1: | 417 STATE ST STE 121 | ||||||||
| Address2: | |||||||||
| City: | BANGOR | ||||||||
| State: | ME | ||||||||
| PostalCode: | 044016630 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2079734266 | ||||||||
| FaxNumber: | 2079735151 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/10/2006 | ||||||||
| LastUpdateDate: | 02/28/2012 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | ME100673 | FL | N | Allopathic & Osteopathic Physicians | Internal Medicine | 207RG0100X | 018950 | ME | Y | Allopathic & Osteopathic Physicians | Internal Medicine | Gastroenterology |
ID Information
| ID | Type | State | Issuer | Description | 280216300 | 05 | FL | MEDICAID | 1033206941 | 05 | ME | MEDICAID |