Provider Demographics
NPI:1518012483
Name:LARSEN, DAVID S (MD)
Entity Type:Individual
Prefix:
First Name:DAVID
Middle Name:S
Last Name:LARSEN
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 1:3351 HOBSON RD.
Mailing Address - Street 2:SUITE A
Mailing Address - City:WOODRIDGE
Mailing Address - State:IL
Mailing Address - Zip Code:60517-1689
Mailing Address - Country:US
Mailing Address - Phone:630-719-0900
Mailing Address - Fax:630-719-0902
Practice Address - Street 1:3351 HOBSON RD.
Practice Address - Street 2:SUITE A
Practice Address - City:WOODRIDGE
Practice Address - State:IL
Practice Address - Zip Code:60517-1689
Practice Address - Country:US
Practice Address - Phone:630-719-0900
Practice Address - Fax:630-719-0902
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-23
Last Update Date:2012-03-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL0360925262084N0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurology
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILG23202Medicare UPIN