Basic Information
| Provider Information | |||||||||
| NPI: | 1598793226 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | LARSON | ||||||||
| FirstName: | TOM | ||||||||
| MiddleName: | D | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 7595 ANAGRAM DR | ||||||||
| Address2: | |||||||||
| City: | EDEN PRAIRIE | ||||||||
| State: | MN | ||||||||
| PostalCode: | 553447399 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6125732200 | ||||||||
| FaxNumber: | 6125732250 | ||||||||
| Practice Location | |||||||||
| Address1: | 7595 ANAGRAM DR | ||||||||
| Address2: | |||||||||
| City: | EDEN PRAIRIE | ||||||||
| State: | MN | ||||||||
| PostalCode: | 553447399 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6125732200 | ||||||||
| FaxNumber: | 6125732250 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/29/2006 | ||||||||
| LastUpdateDate: | 07/21/2022 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 07/07/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2085R0202X | 43983 | MN | Y | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology |
ID Information
| ID | Type | State | Issuer | Description | 16-04032 | 01 | MN | LARSON MEDICA # | OTHER | HP25797 | 01 | MN | LARSON HEALTHPARTNERS # | OTHER | 1015556 | 01 | MN | LARSON PREFERRED ONE # | OTHER | 163020200 | 05 | MN | MEDICAID | 03N49LA | 01 | MN | LARSON BCBS # | OTHER | 18046 | 05 | ND | MEDICAID |