Provider Demographics
NPI:1831651868
Name:LARSON, MARK DANIEL (MD)
Entity type:Individual
Prefix:
First Name:MARK
Middle Name:DANIEL
Last Name:LARSON
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4600 W LOOMIS RD STE 310
Mailing Address - Street 2:
Mailing Address - City:GREENFIELD
Mailing Address - State:WI
Mailing Address - Zip Code:53220-4858
Mailing Address - Country:US
Mailing Address - Phone:414-281-0424
Mailing Address - Fax:414-281-0959
Practice Address - Street 1:4600 W LOOMIS RD STE 310
Practice Address - Street 2:
Practice Address - City:GREENFIELD
Practice Address - State:WI
Practice Address - Zip Code:53220-4858
Practice Address - Country:US
Practice Address - Phone:414-281-0424
Practice Address - Fax:414-281-0959
Is Sole Proprietor?:No
Enumeration Date:2019-03-31
Last Update Date:2024-09-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI84144-20207WX0009X
MN73841207W00000X, 207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207WX0009XAllopathic & Osteopathic PhysiciansOphthalmologyGlaucoma Specialist
No207W00000XAllopathic & Osteopathic PhysiciansOphthalmology