Basic Information
| Provider Information | |||||||||
| NPI: | 1104819622 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | LARSEN | ||||||||
| FirstName: | JEFF | ||||||||
| MiddleName: | D | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1687 E DIVISION ST | ||||||||
| Address2: | |||||||||
| City: | RIVER FALLS | ||||||||
| State: | WI | ||||||||
| PostalCode: | 54022 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7154256701 | ||||||||
| FaxNumber: | 7154257075 | ||||||||
| Practice Location | |||||||||
| Address1: | 1687 E DIVISION ST | ||||||||
| Address2: | |||||||||
| City: | RIVER FALLS | ||||||||
| State: | WI | ||||||||
| PostalCode: | 54022 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7154256701 | ||||||||
| FaxNumber: | 7154257075 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/30/2005 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | X | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | 37621 | WI | Y | Allopathic & Osteopathic Physicians | Internal Medicine |
ID Information
| ID | Type | State | Issuer | Description | 32225000 | 05 | WI | MEDICAID |