Provider Demographics
NPI:1073540167
Name:LARSEN, SHAUN DEAN (OD)
Entity Type:Individual
Prefix:DR
First Name:SHAUN
Middle Name:DEAN
Last Name:LARSEN
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3665 S 8400 W
Mailing Address - Street 2:SUITE 100
Mailing Address - City:MAGNA
Mailing Address - State:UT
Mailing Address - Zip Code:84044-2214
Mailing Address - Country:US
Mailing Address - Phone:801-250-5745
Mailing Address - Fax:801-250-5981
Practice Address - Street 1:3665 S 8400 W
Practice Address - Street 2:SUITE 100
Practice Address - City:MAGNA
Practice Address - State:UT
Practice Address - Zip Code:84044-2214
Practice Address - Country:US
Practice Address - Phone:801-250-5745
Practice Address - Fax:801-250-5981
Is Sole Proprietor?:No
Enumeration Date:2006-06-26
Last Update Date:2010-08-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT3758049934152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT000057039Medicare ID - Type Unspecified
UTU75258Medicare UPIN
UT000055995Medicare ID - Type Unspecified
UT4905670001Medicare NSC