Provider Demographics
NPI:1568443091
Name:LARSON, ROBERT ARIC (OD)
Entity Type:Individual
Prefix:
First Name:ROBERT
Middle Name:ARIC
Last Name:LARSON
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 1:15420 S ROUTE 59
Mailing Address - Street 2:STE #7
Mailing Address - City:PLAINFIELD
Mailing Address - State:IL
Mailing Address - Zip Code:60544-1984
Mailing Address - Country:US
Mailing Address - Phone:815-436-8955
Mailing Address - Fax:
Practice Address - Street 1:15420 S ROUTE 59
Practice Address - Street 2:STE #7
Practice Address - City:PLAINFIELD
Practice Address - State:IL
Practice Address - Zip Code:60544-1984
Practice Address - Country:US
Practice Address - Phone:815-436-8955
Practice Address - Fax:
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-11-10
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
T37682Medicare UPIN