Provider Demographics
NPI:1750300091
Name:LARSON, PATRICIA A (MD)
Entity Type:Individual
Prefix:
First Name:PATRICIA
Middle Name:A
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:PO BOX 529
Mailing Address - Street 2:
Mailing Address - City:ITASCA
Mailing Address - State:IL
Mailing Address - Zip Code:60143-0529
Mailing Address - Country:US
Mailing Address - Phone:847-981-9699
Mailing Address - Fax:
Practice Address - Street 1:901 BIESTERFIELD RD STE 213
Practice Address - Street 2:
Practice Address - City:ELK GROVE VILLAGE
Practice Address - State:IL
Practice Address - Zip Code:60007
Practice Address - Country:US
Practice Address - Phone:847-690-9767
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-18
Last Update Date:2018-07-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036050093207R00000X, 207RI0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RI0200XAllopathic & Osteopathic PhysiciansInternal MedicineInfectious Disease
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
212087OtherGROUP MEDICARE
01633976OtherBC/BS
212087OtherGROUP MEDICARE
K19814Medicare ID - Type Unspecified