Provider Demographics
NPI:1750744421
Name:LARSEN, BRETT ROBERT (MD)
Entity type:Individual
Prefix:
First Name:BRETT
Middle Name:ROBERT
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 1:3903 HARRISON BLVD
Mailing Address - Street 2:100
Mailing Address - City:OGDEN
Mailing Address - State:UT
Mailing Address - Zip Code:84403-2361
Mailing Address - Country:US
Mailing Address - Phone:801-387-7466
Mailing Address - Fax:
Practice Address - Street 1:3903 HARRISON BLVD
Practice Address - Street 2:100
Practice Address - City:OGDEN
Practice Address - State:UT
Practice Address - Zip Code:84403-2361
Practice Address - Country:US
Practice Address - Phone:801-387-7466
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-03-31
Last Update Date:2023-08-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT12220359-12052085N0700X, 2085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
No2085N0700XAllopathic & Osteopathic PhysiciansRadiologyNeuroradiology