Healthcare Provider Details

I. General information

NPI: 1912293135
Provider Name (Legal Business Name): ERIC M LARSEN DPM
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/27/2011
Last Update Date: 03/26/2020
Certification Date: 03/26/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1610 W TOWNLINE ST
CRESTON IA
50801-1066
US

IV. Provider business mailing address

1700 W TOWNLINE ST
CRESTON IA
50801-1054
US

V. Phone/Fax

Practice location:
  • Phone: 641-782-3887
  • Fax: 641-782-6425
Mailing address:
  • Phone: 641-782-7091
  • Fax: 641-782-3830

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code213E00000X
TaxonomyPodiatrist
License Number99537
License Number StateIA
# 2
Primary TaxonomyN
Taxonomy Code213ES0103X
TaxonomyFoot & Ankle Surgery Podiatrist
License NumberPO3759
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: