Provider Demographics
NPI:1013166990
Name:LARSON, JEFFREY A (MD)
Entity Type:Individual
Prefix:DR
First Name:JEFFREY
Middle Name:A
Last Name:LARSON
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 100174
Mailing Address - Street 2:
Mailing Address - City:COLUMBIA
Mailing Address - State:SC
Mailing Address - Zip Code:29202-3174
Mailing Address - Country:US
Mailing Address - Phone:864-716-6100
Mailing Address - Fax:864-716-6120
Practice Address - Street 1:2000 E GREENVILLE ST
Practice Address - Street 2:
Practice Address - City:ANDERSON
Practice Address - State:SC
Practice Address - Zip Code:29621-1580
Practice Address - Country:US
Practice Address - Phone:864-716-6100
Practice Address - Fax:864-716-6120
Is Sole Proprietor?:No
Enumeration Date:2008-09-16
Last Update Date:2020-08-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2013019928208800000X
SC83826208800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208800000XAllopathic & Osteopathic PhysiciansUrology
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL$$$$$$$$$Medicaid