Provider Demographics
NPI:1881883585
Name:ROBERT A LARSON OD PC
Entity type:Organization
Organization Name:ROBERT A LARSON OD PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:ARIC
Authorized Official - Last Name:LARSON
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:815-436-8955
Mailing Address - Street 1:15420 S RTE 59
Mailing Address - Street 2:
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:815-496-8745
Practice Address - Street 1:15420 S RTE 59
Practice Address - Street 2:
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:815-496-8745
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-10-18
Last Update Date:2008-10-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL0142300001OtherPTAN
IL0142300001OtherPTAN