Healthcare Provider Details

I. General information

NPI: 1912967688
Provider Name (Legal Business Name): MELISSA LEIGH LARSON M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/25/2006
Last Update Date: 09/16/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1725 W HARRISON ST SUITE 809
CHICAGO IL
60612-3841
US

IV. Provider business mailing address

1725 W HARRISON ST SUITE 809
CHICAGO IL
60612-3841
US

V. Phone/Fax

Practice location:
  • Phone: 312-563-2320
  • Fax:
Mailing address:
  • Phone: 312-563-2320
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RH0000X
TaxonomyHematology (Internal Medicine) Physician
License Number036108941
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: