Provider Demographics
NPI:1356724272
Name:LARSON, BRYAN KENT (OD)
Entity type:Individual
Prefix:DR
First Name:BRYAN
Middle Name:KENT
Last Name:LARSON
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10 TAFT ST S
Mailing Address - Street 2:
Mailing Address - City:HUMBOLDT
Mailing Address - State:IA
Mailing Address - Zip Code:50548-2037
Mailing Address - Country:US
Mailing Address - Phone:515-332-2950
Mailing Address - Fax:515-332-4451
Practice Address - Street 1:10 TAFT ST S
Practice Address - Street 2:
Practice Address - City:HUMBOLDT
Practice Address - State:IA
Practice Address - Zip Code:50548-2037
Practice Address - Country:US
Practice Address - Phone:515-332-2950
Practice Address - Fax:515-332-4451
Is Sole Proprietor?:No
Enumeration Date:2015-07-09
Last Update Date:2016-01-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA078300152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IAIB3531001Medicare PIN