Provider Demographics
NPI:1952488595
Name:LARSEN, JERROLD L (OD)
Entity Type:Individual
Prefix:DR
First Name:JERROLD
Middle Name:L
Last Name:LARSEN
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1940 E 1ST ST
Mailing Address - Street 2:
Mailing Address - City:CASPER
Mailing Address - State:WY
Mailing Address - Zip Code:82601-2747
Mailing Address - Country:US
Mailing Address - Phone:307-266-9988
Mailing Address - Fax:307-266-9992
Practice Address - Street 1:1940 E 1ST ST
Practice Address - Street 2:
Practice Address - City:CASPER
Practice Address - State:WY
Practice Address - Zip Code:82601-2747
Practice Address - Country:US
Practice Address - Phone:307-266-9988
Practice Address - Fax:307-266-9992
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-01
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WY157T152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WYW9993Medicare ID - Type Unspecified
WYT44153Medicare UPIN