Basic Information
| Provider Information | |||||||||
| NPI: | 1730167768 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | LARSON | ||||||||
| FirstName: | ROBERT | ||||||||
| MiddleName: | M | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1230 E MAIN ST | ||||||||
| Address2: | PO BOX 8674 | ||||||||
| City: | MANKATO | ||||||||
| State: | MN | ||||||||
| PostalCode: | 560028674 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5076251811 | ||||||||
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| Practice Location | |||||||||
| Address1: | 1230 E MAIN ST | ||||||||
| Address2: | |||||||||
| City: | MANKATO | ||||||||
| State: | MN | ||||||||
| PostalCode: | 560028674 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5076251811 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/09/2006 | ||||||||
| LastUpdateDate: | 07/10/2020 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 07/10/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208000000X | 21174 | MN | Y | Allopathic & Osteopathic Physicians | Pediatrics |
ID Information
| ID | Type | State | Issuer | Description | 32427900 | 05 | WI | MEDICAID | 1201389 | 01 | MN | MEDICA | OTHER | 1507723 | 05 | IA | MEDICAID | 41084933956001C018 | 01 | CHAMPUS | OTHER | 46D53LA | 01 | MN | BCBS | OTHER | 789282900 | 05 | MN | MEDICAID | HP10853 | 01 | MN | HEALTH PARTNERS | OTHER | NA2951027857 | 01 | MN | PREFERRED ONE | OTHER | 770978 | 01 | MN | AMERICAS PPO | OTHER | 109799 | 01 | MN | UCARE | OTHER | 370019734 | 01 | RR MEDICARE | OTHER |