Healthcare Provider Details

I. General information

NPI: 1083871974
Provider Name (Legal Business Name): BRIAN LARSEN M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/19/2008
Last Update Date: 06/04/2026
Certification Date: 06/04/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

477 E BUTTERFIELD RD STE 105
LOMBARD IL
60148-5622
US

IV. Provider business mailing address

PO BOX 737505
CHICAGO IL
60673-7505
US

V. Phone/Fax

Practice location:
  • Phone: 773-943-7425
  • Fax: 773-896-0303
Mailing address:
  • Phone: 773-943-7425
  • Fax: 773-896-0303

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207WX0107X
TaxonomyRetina Specialist (Ophthalmology) Physician
License Number036129978
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code207W00000X
TaxonomyOphthalmology Physician
License Number036129978
License Number StateIL
# 3
Primary TaxonomyN
Taxonomy Code207W00000X
TaxonomyOphthalmology Physician
License Number54511
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: