Healthcare Provider Details

I. General information

NPI: 1861478364
Provider Name (Legal Business Name): WILMA I. LARSEN M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/16/2005
Last Update Date: 11/12/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2401 S 31ST ST
TEMPLE TX
76508-0001
US

IV. Provider business mailing address

PO BOX 844658
DALLAS TX
75284-4658
US

V. Phone/Fax

Practice location:
  • Phone: 254-724-2111
  • Fax:
Mailing address:
  • Phone: 254-724-2111
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207V00000X
TaxonomyObstetrics & Gynecology Physician
License NumberMD053692L
License Number StatePA
# 2
Primary TaxonomyY
Taxonomy Code207V00000X
TaxonomyObstetrics & Gynecology Physician
License NumberN5181
License Number StateTX
# 3
Primary TaxonomyN
Taxonomy Code207VF0040X
TaxonomyUrogynecology and Reconstructive Pelvic Surgery (Obstetrics & Gynecology) Physician
License NumberN5181
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: