Provider Demographics
NPI:1912293135
Name:LARSEN, ERIC M (DPM)
Entity Type:Individual
Prefix:DR
First Name:ERIC
Middle Name:M
Last Name:LARSEN
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1700 W TOWNLINE ST
Mailing Address - Street 2:
Mailing Address - City:CRESTON
Mailing Address - State:IA
Mailing Address - Zip Code:50801-1054
Mailing Address - Country:US
Mailing Address - Phone:641-782-7091
Mailing Address - Fax:641-782-3830
Practice Address - Street 1:1610 W TOWNLINE ST
Practice Address - Street 2:
Practice Address - City:CRESTON
Practice Address - State:IA
Practice Address - Zip Code:50801-1066
Practice Address - Country:US
Practice Address - Phone:641-782-3887
Practice Address - Fax:641-782-6425
Is Sole Proprietor?:No
Enumeration Date:2011-06-27
Last Update Date:2020-03-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPO3759213ES0103X
IA99537213E00000X
IL016005634213ES0103X
WI1041-25213ES0103X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle Surgery
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLIJ338ZMedicare PIN
WI100037193Medicaid
IL016005634Medicaid
WIK400183139Medicare PIN