Provider Demographics
NPI:1295773166
Name:LARSEN, WILHELM CJ (MD)
Entity type:Individual
Prefix:
First Name:WILHELM
Middle Name:CJ
Last Name:LARSEN
Suffix:
Gender:M
Credentials:MD
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Mailing Address - Street 1:1065 NE 125TH STREET
Mailing Address - Street 2:SUITE 409
Mailing Address - City:NORTH MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33161-5834
Mailing Address - Country:US
Mailing Address - Phone:888-852-6672
Mailing Address - Fax:305-891-4228
Practice Address - Street 1:10301 HAGEN RANCH ROAD
Practice Address - Street 2:SUITE B6
Practice Address - City:BOYNTON BEACH
Practice Address - State:FL
Practice Address - Zip Code:33437-3723
Practice Address - Country:US
Practice Address - Phone:561-752-9490
Practice Address - Fax:561-752-9491
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-03
Last Update Date:2017-01-20
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
FLME27507207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL274949100Medicaid
FLD53906Medicare UPIN
FL30237YMedicare PIN