Basic Information
| Provider Information | |||||||||
| NPI: | 1891770947 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | LARSON | ||||||||
| FirstName: | GERALD | ||||||||
| MiddleName: | L | ||||||||
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| Credential: | DO | ||||||||
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| Mailing Information | |||||||||
| Address1: | 401 S BALLENGER HWY | ||||||||
| Address2: | |||||||||
| City: | FLINT | ||||||||
| State: | MI | ||||||||
| PostalCode: | 485323638 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8103421000 | ||||||||
| FaxNumber: | 8103421590 | ||||||||
| Practice Location | |||||||||
| Address1: | 1459 S CENTER RD | ||||||||
| Address2: | |||||||||
| City: | BURTON | ||||||||
| State: | MI | ||||||||
| PostalCode: | 485091726 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8104960900 | ||||||||
| FaxNumber: | 8107423891 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/13/2005 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | X | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 5101007523 | MI | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | F19561 | 01 | MI | HAP | OTHER | F19561 | 01 | MI | HEALTH NET FEDERAL SERVIC | OTHER | 3302490 | 05 | MI | MEDICAID |