Provider Demographics
NPI:1407969645
Name:LARSON, BETH E (MD)
Entity Type:Individual
Prefix:DR
First Name:BETH
Middle Name:E
Last Name:LARSON
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2001 N GARY AVE
Mailing Address - Street 2:
Mailing Address - City:WHEATON
Mailing Address - State:IL
Mailing Address - Zip Code:60187-3264
Mailing Address - Country:US
Mailing Address - Phone:630-614-4100
Mailing Address - Fax:630-614-4048
Practice Address - Street 1:2001 S WIESBROOK RD
Practice Address - Street 2:
Practice Address - City:WHEATON
Practice Address - State:IL
Practice Address - Zip Code:60189
Practice Address - Country:US
Practice Address - Phone:630-614-4000
Practice Address - Fax:630-614-4048
Is Sole Proprietor?:No
Enumeration Date:2006-08-15
Last Update Date:2018-06-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036069259207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILL81964OtherMEDICARE PTAN (INDIVIDUAL)
IL036069259Medicaid
IL592050Medicare ID - Type Unspecified
IL036069259Medicaid
ILE42121Medicare UPIN