Provider Demographics
NPI:1184768129
Name:LARSON, CHARLES E (MD)
Entity type:Individual
Prefix:DR
First Name:CHARLES
Middle Name:E
Last Name:LARSON
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
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Mailing Address - Street 1:W4455 OVERLAND TRL
Mailing Address - Street 2:
Mailing Address - City:FOND DU LAC
Mailing Address - State:WI
Mailing Address - Zip Code:54935-8525
Mailing Address - Country:US
Mailing Address - Phone:920-924-9630
Mailing Address - Fax:
Practice Address - Street 1:FLCI
Practice Address - Street 2:W10237 LAKE EMILY RD
Practice Address - City:FOX LAKE
Practice Address - State:WI
Practice Address - Zip Code:54935-8525
Practice Address - Country:US
Practice Address - Phone:920-928-6958
Practice Address - Fax:920-928-6951
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-15
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI26821207QA0505X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207QA0505XAllopathic & Osteopathic PhysiciansFamily MedicineAdult Medicine