Provider Demographics
NPI:1053729152
Name:LARSON, BRADLY KENDALL (OD)
Entity type:Individual
Prefix:DR
First Name:BRADLY
Middle Name:KENDALL
Last Name:LARSON
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
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Mailing Address - Street 1:8889 JEWELLA AVE STE C
Mailing Address - Street 2:
Mailing Address - City:SHREVEPORT
Mailing Address - State:LA
Mailing Address - Zip Code:71118-2138
Mailing Address - Country:US
Mailing Address - Phone:318-686-5227
Mailing Address - Fax:381-686-5283
Practice Address - Street 1:8889 JEWELLA AVE STE C
Practice Address - Street 2:
Practice Address - City:SHREVEPORT
Practice Address - State:LA
Practice Address - Zip Code:71118-2138
Practice Address - Country:US
Practice Address - Phone:318-686-5227
Practice Address - Fax:381-686-5283
Is Sole Proprietor?:Yes
Enumeration Date:2014-08-01
Last Update Date:2014-08-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA1775-709T152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist