Provider Demographics
NPI:1043335078
Name:LARSEN, MARK WILLIAM (DC)
Entity type:Individual
Prefix:DR
First Name:MARK
Middle Name:WILLIAM
Last Name:LARSEN
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7 N WABASH ST
Mailing Address - Street 2:
Mailing Address - City:PERU
Mailing Address - State:IN
Mailing Address - Zip Code:46970-2224
Mailing Address - Country:US
Mailing Address - Phone:765-472-1127
Mailing Address - Fax:765-472-5228
Practice Address - Street 1:7 N WABASH ST
Practice Address - Street 2:
Practice Address - City:PERU
Practice Address - State:IN
Practice Address - Zip Code:46970-2224
Practice Address - Country:US
Practice Address - Phone:765-472-1127
Practice Address - Fax:765-472-5228
Is Sole Proprietor?:No
Enumeration Date:2007-03-20
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN08001019A111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN000000092330OtherANTHEM WELLPOINT
IN000000092330OtherANTHEM WELLPOINT