Provider Demographics
NPI:1932176773
Name:LARSON, BRUCE (MD)
Entity Type:Individual
Prefix:
First Name:BRUCE
Middle Name:
Last Name:LARSON
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 1:126 W FIRST ST
Mailing Address - Street 2:
Mailing Address - City:HINSDALE
Mailing Address - State:IL
Mailing Address - Zip Code:60521-4013
Mailing Address - Country:US
Mailing Address - Phone:630-325-5200
Mailing Address - Fax:630-325-5569
Practice Address - Street 1:126 W FIRST ST
Practice Address - Street 2:
Practice Address - City:HINSDALE
Practice Address - State:IL
Practice Address - Zip Code:60521-4013
Practice Address - Country:US
Practice Address - Phone:630-325-5200
Practice Address - Fax:630-325-5569
Is Sole Proprietor?:No
Enumeration Date:2006-03-01
Last Update Date:2010-07-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL36066594207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILL08359OtherMEDICARE PTAN
IL0346350001Medicare NSC
IL207088Medicare PIN
ILK01229Medicare PIN
ILL08359OtherMEDICARE PTAN
ILK01229Medicare ID - Type Unspecified
U43591Medicare UPIN