Provider Demographics
NPI:1497722904
Name:LARSON, JEFFREY STEPHEN (OD)
Entity Type:Individual
Prefix:
First Name:JEFFREY
Middle Name:STEPHEN
Last Name:LARSON
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:JEFF
Other - Middle Name:
Other - Last Name:LARSON
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:8100 34TH AVE S
Mailing Address - Street 2:21110Q
Mailing Address - City:BLOOMINGTON
Mailing Address - State:MN
Mailing Address - Zip Code:55425-1672
Mailing Address - Country:US
Mailing Address - Phone:952-883-7961
Mailing Address - Fax:952-883-5395
Practice Address - Street 1:5100 GAMBLE DR SUITE 100
Practice Address - Street 2:MAIL STOP 31200A
Practice Address - City:SAINT LOUIS PARK
Practice Address - State:MN
Practice Address - Zip Code:55416-1582
Practice Address - Country:US
Practice Address - Phone:952-593-8777
Practice Address - Fax:952-595-6408
Is Sole Proprietor?:No
Enumeration Date:2006-03-02
Last Update Date:2011-10-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN1999152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN057523200Medicaid
T92802Medicare UPIN
MN410001034Medicare ID - Type Unspecified