Healthcare Provider Details

I. General information

NPI: 1831651868
Provider Name (Legal Business Name): MARK DANIEL LARSON MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/31/2019
Last Update Date: 09/10/2024
Certification Date: 09/10/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4600 W LOOMIS RD STE 310
GREENFIELD WI
53220-4858
US

IV. Provider business mailing address

4600 W LOOMIS RD STE 310
GREENFIELD WI
53220-4858
US

V. Phone/Fax

Practice location:
  • Phone: 414-281-0424
  • Fax: 414-281-0959
Mailing address:
  • Phone: 414-281-0424
  • Fax: 414-281-0959

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207WX0009X
TaxonomyGlaucoma Specialist (Ophthalmology) Physician
License Number84144-20
License Number StateWI
# 2
Primary TaxonomyN
Taxonomy Code207W00000X
TaxonomyOphthalmology Physician
License Number73841
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: