Provider Demographics
NPI:1770553620
Name:LARSON, BOBBY HAROLD (DO)
Entity type:Individual
Prefix:DR
First Name:BOBBY
Middle Name:HAROLD
Last Name:LARSON
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:125 RANDOLPH RD
Mailing Address - Street 2:
Mailing Address - City:OAK RIDGE
Mailing Address - State:TN
Mailing Address - Zip Code:37830-5028
Mailing Address - Country:US
Mailing Address - Phone:865-482-7565
Mailing Address - Fax:865-482-7551
Practice Address - Street 1:125 RANDOLPH RD
Practice Address - Street 2:
Practice Address - City:OAK RIDGE
Practice Address - State:TN
Practice Address - Zip Code:37830-5028
Practice Address - Country:US
Practice Address - Phone:865-482-7565
Practice Address - Fax:865-482-7551
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-01-24
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNOD0677152W00000X
KY89OD152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN0122010OtherCLARITY VISION
TN44608OtherDAVIS VISION
NE3123670OtherBLUE CROSS BLUE SHIELD
TNT61209Medicare UPIN
NE3123670OtherBLUE CROSS BLUE SHIELD