Provider Demographics
NPI:1316047079
Name:LARSON, BEN L (OD)
Entity type:Individual
Prefix:DR
First Name:BEN
Middle Name:L
Last Name:LARSON
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
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Mailing Address - Street 1:5680 WAYSIDE DR
Mailing Address - Street 2:
Mailing Address - City:SANFORD
Mailing Address - State:FL
Mailing Address - Zip Code:32771-8625
Mailing Address - Country:US
Mailing Address - Phone:407-333-3937
Mailing Address - Fax:407-333-4500
Practice Address - Street 1:5680 WAYSIDE DR
Practice Address - Street 2:
Practice Address - City:SANFORD
Practice Address - State:FL
Practice Address - Zip Code:32771-8625
Practice Address - Country:US
Practice Address - Phone:407-333-3937
Practice Address - Fax:407-333-4500
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-23
Last Update Date:2010-09-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOPC 3014152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLU73637Medicare UPIN