Healthcare Provider Details

I. General information

NPI: 1881883585
Provider Name (Legal Business Name): ROBERT A LARSON OD PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/18/2007
Last Update Date: 10/17/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

15420 S RTE 59
PLAINFIELD IL
60544-1984
US

IV. Provider business mailing address

15420 S RTE 59
PLAINFIELD IL
60544-1984
US

V. Phone/Fax

Practice location:
  • Phone: 815-436-8955
  • Fax: 815-496-8745
Mailing address:
  • Phone: 815-436-8955
  • Fax: 815-496-8745

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261Q00000X
TaxonomyClinic/Center
License Number
License Number State

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
Identifier0142300001
Identifier TypeOTHER
Identifier StateIL
Identifier IssuerPTAN

VIII. Authorized Official

Name: DR. ROBERT ARIC LARSON
Title or Position: OWNER
Credential: O.D.
Phone: 815-436-8955