Provider Demographics
NPI:1912967688
Name:LARSON, MELISSA LEIGH (MD)
Entity Type:Individual
Prefix:DR
First Name:MELISSA
Middle Name:LEIGH
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 1:1725 W HARRISON ST
Mailing Address - Street 2:SUITE 809
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60612-3841
Mailing Address - Country:US
Mailing Address - Phone:312-563-2320
Mailing Address - Fax:
Practice Address - Street 1:1725 W HARRISON ST
Practice Address - Street 2:SUITE 809
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60612-3841
Practice Address - Country:US
Practice Address - Phone:312-563-2320
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-03-25
Last Update Date:2011-09-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036108941207RH0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RH0000XAllopathic & Osteopathic PhysiciansInternal MedicineHematology
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILI53889Medicare UPIN
ILK28433Medicare ID - Type Unspecified