Provider Demographics
NPI:1609062363
Name:LARSEN, JEFFREY A (MD)
Entity Type:Individual
Prefix:DR
First Name:JEFFREY
Middle Name:A
Last Name:LARSEN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:MR
Other - First Name:JEFFREY
Other - Middle Name:ARTHUR
Other - Last Name:LARSEN
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:300 STONECREST BLVD
Mailing Address - Street 2:SUITE 360
Mailing Address - City:SMYRNA
Mailing Address - State:TN
Mailing Address - Zip Code:37167-6818
Mailing Address - Country:US
Mailing Address - Phone:615-223-9935
Mailing Address - Fax:615-768-7871
Practice Address - Street 1:300 STONECREST BLVD
Practice Address - Street 2:SUITE 360
Practice Address - City:SMYRNA
Practice Address - State:TN
Practice Address - Zip Code:37167-6818
Practice Address - Country:US
Practice Address - Phone:615-223-9935
Practice Address - Fax:615-768-2021
Is Sole Proprietor?:No
Enumeration Date:2007-09-17
Last Update Date:2020-10-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN30866208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN1529941Medicaid
TNG91339Medicare UPIN
TN38367641Medicare PIN