Provider Demographics
NPI:1285788950
Name:MELICHER LARSON, JILL SUZANNE (MD)
Entity type:Individual
Prefix:
First Name:JILL
Middle Name:SUZANNE
Last Name:MELICHER LARSON
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:JILL
Other - Middle Name:SUZANNE
Other - Last Name:MELICHER
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MD
Mailing Address - Street 1:9801 DUPONT AVE S
Mailing Address - Street 2:SUITE 425
Mailing Address - City:BLOOMINGTON
Mailing Address - State:MN
Mailing Address - Zip Code:55431-3100
Mailing Address - Country:US
Mailing Address - Phone:952-888-5800
Mailing Address - Fax:
Practice Address - Street 1:9801 DUPONT AVE S
Practice Address - Street 2:200
Practice Address - City:BLOOMINGTON
Practice Address - State:MN
Practice Address - Zip Code:55431-3100
Practice Address - Country:US
Practice Address - Phone:952-888-5800
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-01-22
Last Update Date:2017-10-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN105147207W00000X
MN53626207WX0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207WX0200XAllopathic & Osteopathic PhysiciansOphthalmologyOphthalmic Plastic and Reconstructive Surgery
No207W00000XAllopathic & Osteopathic PhysiciansOphthalmology