Provider Demographics
NPI:1275513467
Name:LARSON, ERIC M (MD)
Entity Type:Individual
Prefix:
First Name:ERIC
Middle Name:M
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:PO BOX 2723
Mailing Address - Street 2:
Mailing Address - City:OSHKOSH
Mailing Address - State:WI
Mailing Address - Zip Code:54903-2723
Mailing Address - Country:US
Mailing Address - Phone:920-232-6550
Mailing Address - Fax:920-232-6552
Practice Address - Street 1:1885 WEST POINTE DR
Practice Address - Street 2:
Practice Address - City:OSHKOSH
Practice Address - State:WI
Practice Address - Zip Code:54902-4174
Practice Address - Country:US
Practice Address - Phone:920-232-6550
Practice Address - Fax:920-232-6552
Is Sole Proprietor?:No
Enumeration Date:2006-01-23
Last Update Date:2013-07-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI45716207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI34413200Medicaid
WI69015-0003Medicare ID - Type Unspecified
WI71490-003Medicare ID - Type Unspecified
WI26020-0003Medicare ID - Type Unspecified
WI34413200Medicaid
P00030693Medicare PIN