Provider Demographics
NPI:1275527095
Name:OCULOPLASTICS OF SOUTHWEST FLORIDA, DEAN W. LARSON, MD PA
Entity Type:Organization
Organization Name:OCULOPLASTICS OF SOUTHWEST FLORIDA, DEAN W. LARSON, MD PA
Other - Org Name:EYELID SURGERY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:DEAN
Authorized Official - Middle Name:WILLIAM
Authorized Official - Last Name:LARSON
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:239-481-9995
Mailing Address - Street 1:15620 NEW HAMPSHIRE CT
Mailing Address - Street 2:
Mailing Address - City:FORT MYERS
Mailing Address - State:FL
Mailing Address - Zip Code:33908-4168
Mailing Address - Country:US
Mailing Address - Phone:239-481-9995
Mailing Address - Fax:239-481-9745
Practice Address - Street 1:15620 NEW HAMPSHIRE CT
Practice Address - Street 2:
Practice Address - City:FORT MYERS
Practice Address - State:FL
Practice Address - Zip Code:33908-4168
Practice Address - Country:US
Practice Address - Phone:239-481-9995
Practice Address - Fax:239-481-9745
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-09-08
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL207W00000X, 367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Not Answered207W00000XAllopathic & Osteopathic PhysiciansOphthalmologyGroup - Multi-Specialty
Not Answered367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified RegisteredGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLDC9277OtherRAILROAD MEDICARE
K5561Medicare ID - Type UnspecifiedGROUP NUMBER