Provider Demographics
NPI:1609184365
Name:LARSON, TODD ROBERT (DO)
Entity Type:Individual
Prefix:
First Name:TODD
Middle Name:ROBERT
Last Name:LARSON
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1442 N 31ST ST
Mailing Address - Street 2:
Mailing Address - City:SHEBOYGAN
Mailing Address - State:WI
Mailing Address - Zip Code:53081-3061
Mailing Address - Country:US
Mailing Address - Phone:920-452-5400
Mailing Address - Fax:920-452-1920
Practice Address - Street 1:1442 N 31ST ST
Practice Address - Street 2:
Practice Address - City:SHEBOYGAN
Practice Address - State:WI
Practice Address - Zip Code:53081-3061
Practice Address - Country:US
Practice Address - Phone:920-452-5400
Practice Address - Fax:920-452-1920
Is Sole Proprietor?:No
Enumeration Date:2010-09-15
Last Update Date:2021-12-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI55136-021207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology