Provider Demographics
NPI:1649353947
Name:LARSON, JEFFREY J (MD)
Entity type:Individual
Prefix:DR
First Name:JEFFREY
Middle Name:J
Last Name:LARSON
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:3320 N GRAND MILL LN
Mailing Address - Street 2:
Mailing Address - City:COEUR D ALENE
Mailing Address - State:ID
Mailing Address - Zip Code:83814-5689
Mailing Address - Country:US
Mailing Address - Phone:208-765-9100
Mailing Address - Fax:208-765-9103
Practice Address - Street 1:3320 N GRAND MILL LN
Practice Address - Street 2:
Practice Address - City:COEUR D ALENE
Practice Address - State:ID
Practice Address - Zip Code:83814-5689
Practice Address - Country:US
Practice Address - Phone:208-765-9100
Practice Address - Fax:208-765-9103
Is Sole Proprietor?:No
Enumeration Date:2006-10-23
Last Update Date:2024-04-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDM8677207T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207T00000XAllopathic & Osteopathic PhysiciansNeurological Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
205112900OtherOWCP
0172112OtherWASHINGTON L & I
0172112OtherWASHINGTON L & I
IDP00058729OtherRAILROAD MEDICARE
WA8207342Medicaid
ID54791OtherBLUE CROSS OF IDAHO
205112900OtherOWCP
ID804141600Medicaid
IDP00058729OtherRAILROAD MEDICARE
8939563OtherCRIME VICTIMS COMP FUND