Basic Information
Provider Information | |||||||||
NPI: | 1083697635 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | LARSON | ||||||||
FirstName: | WILLIAM | ||||||||
MiddleName: | DAVID | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | MD | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: | LARSON | ||||||||
OtherFirstName: | W | ||||||||
OtherMiddleName: | DAVID | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: | MD | ||||||||
OtherLastNameType: | 2 | ||||||||
Mailing Information | |||||||||
Address1: | 6420 SW MACADAM AVE | ||||||||
Address2: | SUITE 216 | ||||||||
City: | PORTLAND | ||||||||
State: | OR | ||||||||
PostalCode: | 972393507 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5032448601 | ||||||||
FaxNumber: | 5032443013 | ||||||||
Practice Location | |||||||||
Address1: | 19250 SW 65TH AVE | ||||||||
Address2: | STE 215 | ||||||||
City: | TUALATIN | ||||||||
State: | OR | ||||||||
PostalCode: | 970627452 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5036923630 | ||||||||
FaxNumber: | 5036923420 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 11/28/2005 | ||||||||
LastUpdateDate: | 05/29/2013 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207W00000X | MD10715 | OR | Y |   | Allopathic & Osteopathic Physicians | Ophthalmology |   |
ID Information
ID | Type | State | Issuer | Description | 060087 | 05 | OR |   | MEDICAID | 180002095 | 01 | OR | RAILROAD MEDICARE | OTHER |