Provider Demographics
NPI:1063528529
Name:LARSON, KARL C (MD)
Entity type:Individual
Prefix:
First Name:KARL
Middle Name:C
Last Name:LARSON
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2725 JACKSON ST
Mailing Address - Street 2:
Mailing Address - City:OSHKOSH
Mailing Address - State:WI
Mailing Address - Zip Code:54901-1513
Mailing Address - Country:US
Mailing Address - Phone:920-223-7500
Mailing Address - Fax:920-223-7630
Practice Address - Street 1:2725 JACKSON ST
Practice Address - Street 2:
Practice Address - City:OSHKOSH
Practice Address - State:WI
Practice Address - Zip Code:54901-1513
Practice Address - Country:US
Practice Address - Phone:920-223-7500
Practice Address - Fax:920-223-7630
Is Sole Proprietor?:No
Enumeration Date:2006-08-21
Last Update Date:2009-12-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI28253207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
WIA02401OtherCIGNA
WI28253OtherTOUCHPOINT
WI3076200Medicaid
WI080113126OtherMEDICARE RAILROAD
WI20021OtherNETWORK HEALTH
WI710016OtherT19 MANAGED HEALTH SERVIC
WI710016OtherT19 MANAGED HEALTH SERVIC
A02401Medicare UPIN