Provider Demographics
NPI:1003806795
Name:LARSON, SUSAN MANZ (MD)
Entity Type:Individual
Prefix:
First Name:SUSAN
Middle Name:MANZ
Last Name:LARSON
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:SUSAN
Other - Middle Name:B
Other - Last Name:MANZ
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:19475 W NORTH AVE
Mailing Address - Street 2:SUITE 201
Mailing Address - City:BROOKFIELD
Mailing Address - State:WI
Mailing Address - Zip Code:53045-4199
Mailing Address - Country:US
Mailing Address - Phone:262-780-4400
Mailing Address - Fax:262-780-4425
Practice Address - Street 1:2424 S 90TH ST
Practice Address - Street 2:SUITE 500
Practice Address - City:WEST ALLIS
Practice Address - State:WI
Practice Address - Zip Code:53227-2455
Practice Address - Country:US
Practice Address - Phone:414-328-8600
Practice Address - Fax:414-328-8686
Is Sole Proprietor?:No
Enumeration Date:2005-10-25
Last Update Date:2008-01-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI31194020208100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & Rehabilitation
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI31609800Medicaid
WI31609800Medicaid
WID81648Medicare UPIN