Provider Demographics
NPI:1750358693
Name:LARSON, CHRISTOPHER L
Entity type:Individual
Prefix:DR
First Name:CHRISTOPHER
Middle Name:L
Last Name:LARSON
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1442 N 31ST ST
Mailing Address - Street 2:
Mailing Address - City:SHEBOYGAN
Mailing Address - State:WI
Mailing Address - Zip Code:53081-3061
Mailing Address - Country:US
Mailing Address - Phone:920-452-5400
Mailing Address - Fax:920-452-1920
Practice Address - Street 1:1442 N 31ST ST
Practice Address - Street 2:
Practice Address - City:SHEBOYGAN
Practice Address - State:WI
Practice Address - Zip Code:53081-3061
Practice Address - Country:US
Practice Address - Phone:920-452-5400
Practice Address - Fax:920-452-1920
Is Sole Proprietor?:No
Enumeration Date:2006-02-28
Last Update Date:2010-05-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI20209020207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI32866800Medicaid
B85018Medicare UPIN
WI32866800Medicaid