Provider Demographics
NPI:1598734600
Name:LARSON, ROBERT JAMES (OD)
Entity Type:Individual
Prefix:MR
First Name:ROBERT
Middle Name:JAMES
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 1:3501 S SHIELDS ST
Mailing Address - Street 2:
Mailing Address - City:FORT COLLINS
Mailing Address - State:CO
Mailing Address - Zip Code:80526-2583
Mailing Address - Country:US
Mailing Address - Phone:970-490-2020
Mailing Address - Fax:970-221-3121
Practice Address - Street 1:3501 S SHIELDS ST
Practice Address - Street 2:
Practice Address - City:FORT COLLINS
Practice Address - State:CO
Practice Address - Zip Code:80526-2583
Practice Address - Country:US
Practice Address - Phone:970-221-1931
Practice Address - Fax:970-221-1055
Is Sole Proprietor?:No
Enumeration Date:2006-03-14
Last Update Date:2021-04-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO85499152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO08008542Medicaid
CO76983Medicare ID - Type Unspecified