Basic Information
| Provider Information | |||||||||
| NPI: | 1104142678 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | LARSON | ||||||||
| FirstName: | BRETT | ||||||||
| MiddleName: | DAVID | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 712 S CASCADE ST | ||||||||
| Address2: | SUITE 102 | ||||||||
| City: | FERGUS FALLS | ||||||||
| State: | MN | ||||||||
| PostalCode: | 565372913 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2187368000 | ||||||||
| FaxNumber: | 2187396718 | ||||||||
| Practice Location | |||||||||
| Address1: | 1525 E 6000 S STE A | ||||||||
| Address2: | |||||||||
| City: | SOUTH OGDEN | ||||||||
| State: | UT | ||||||||
| PostalCode: | 844057149 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8013375800 | ||||||||
| FaxNumber: | 8013375858 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/08/2010 | ||||||||
| LastUpdateDate: | 08/25/2022 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 08/25/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207V00000X | 60490 | MN | N | Allopathic & Osteopathic Physicians | Obstetrics & Gynecology | 207V00000X | 35125228 | OH | N | Allopathic & Osteopathic Physicians | Obstetrics & Gynecology | 207V00000X | 12706124-1205 | UT | Y | Allopathic & Osteopathic Physicians | Obstetrics & Gynecology |
No ID Information.