Healthcare Provider Details

I. General information

NPI: 1184768129
Provider Name (Legal Business Name): CHARLES E LARSON M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/15/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

FLCI W10237 LAKE EMILY RD
FOX LAKE WI
54935-8525
US

IV. Provider business mailing address

W4455 OVERLAND TRL
FOND DU LAC WI
54935-8525
US

V. Phone/Fax

Practice location:
  • Phone: 920-928-6958
  • Fax: 920-928-6951
Mailing address:
  • Phone: 920-924-9630
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207QA0505X
TaxonomyAdult Medicine Physician
License Number26821
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: