Provider Demographics
NPI:1447513221
Name:LARSEN, EUGENE DOUGLAS JR (DO)
Entity type:Individual
Prefix:
First Name:EUGENE
Middle Name:DOUGLAS
Last Name:LARSEN
Suffix:JR
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:415 N 1095 W
Mailing Address - Street 2:
Mailing Address - City:PRICE
Mailing Address - State:UT
Mailing Address - Zip Code:84501-4243
Mailing Address - Country:US
Mailing Address - Phone:435-637-5690
Mailing Address - Fax:435-637-9809
Practice Address - Street 1:280 N HOSPITAL DR STE 4
Practice Address - Street 2:
Practice Address - City:PRICE
Practice Address - State:UT
Practice Address - Zip Code:84501
Practice Address - Country:US
Practice Address - Phone:435-637-5690
Practice Address - Fax:435-637-9809
Is Sole Proprietor?:Yes
Enumeration Date:2012-06-18
Last Update Date:2018-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT9336977-1204207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT1447513221Medicaid