Provider Demographics
NPI:1144266479
Name:LARSON, JEFFREY D (MD)
Entity type:Individual
Prefix:
First Name:JEFFREY
Middle Name:D
Last Name:LARSON
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:202 S PARK ST
Mailing Address - Street 2:
Mailing Address - City:MADISON
Mailing Address - State:WI
Mailing Address - Zip Code:53715-1507
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:6408 COPPS AVE
Practice Address - Street 2:
Practice Address - City:MONONA
Practice Address - State:WI
Practice Address - Zip Code:53716
Practice Address - Country:US
Practice Address - Phone:608-417-6175
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-06-22
Last Update Date:2019-04-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI50808-20208200000X, 208200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208200000XAllopathic & Osteopathic PhysiciansPlastic Surgery