Provider Demographics
NPI:1255864823
Name:LARSON, JEFFREY (MD)
Entity type:Individual
Prefix:DR
First Name:JEFFREY
Middle Name:
Last Name:LARSON
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:JEFF
Other - Middle Name:
Other - Last Name:LARSON
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MD
Mailing Address - Street 1:2800 CAMPUS DR STE 10
Mailing Address - Street 2:
Mailing Address - City:PLYMOUTH
Mailing Address - State:MN
Mailing Address - Zip Code:55441-8812
Mailing Address - Country:US
Mailing Address - Phone:763-398-4400
Mailing Address - Fax:
Practice Address - Street 1:3366 OAKDALE AVE N STE 401
Practice Address - Street 2:
Practice Address - City:ROBBINSDALE
Practice Address - State:MN
Practice Address - Zip Code:55422-2986
Practice Address - Country:US
Practice Address - Phone:763-398-6383
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-04-10
Last Update Date:2024-05-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
MN67682207RP1001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RP1001XAllopathic & Osteopathic PhysiciansInternal MedicinePulmonary Disease
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program