Provider Demographics
NPI:1134129778
Name:LARSON, HEIDI C (DPM)
Entity Type:Individual
Prefix:
First Name:HEIDI
Middle Name:C
Last Name:LARSON
Suffix:
Gender:F
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 6542
Mailing Address - Street 2:
Mailing Address - City:NAPERVILLE
Mailing Address - State:IL
Mailing Address - Zip Code:60567-6542
Mailing Address - Country:US
Mailing Address - Phone:630-579-9182
Mailing Address - Fax:630-579-6040
Practice Address - Street 1:859 RAINTREE DR
Practice Address - Street 2:
Practice Address - City:NAPERVILLE
Practice Address - State:IL
Practice Address - Zip Code:60540-6382
Practice Address - Country:US
Practice Address - Phone:630-579-9182
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2005-07-26
Last Update Date:2022-02-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL016-004775213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL390410Medicare PIN
ILU61594Medicare UPIN