MEDICARE: JODIE S LARSON OD

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	152W00000X	Optometrist	619	SD

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1417942251
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JODIE S LARSON OD

Provider Business Mailing Address
First Line	:	PO BOX 388
Second Line	:
City	:	MADISON
State	:	SD
Zip	:	57042-0388
Country	:	US
Telephone Number	:	605-256-6911
Fax Number	:	605-256-9017

Provider Business Practice Location Address
First Line	:	302 N HARTH AVE
Second Line	:
City	:	MADISON
State	:	SD
Zip	:	57042-2219
Country	:	US
Telephone Number	:	605-256-6911
Fax Number	:	605-256-9017

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	09/19/2005
Last Update Date	:	10/09/2007

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Directions to “ JODIE S LARSON OD” Practice Location

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