Basic Information
| Provider Information | |||||||||
| NPI: | 1710554019 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BRIGHAM | ||||||||
| FirstName: | LARISSA | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | OD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3200 E RACINE ST | ||||||||
| Address2: | |||||||||
| City: | JANESVILLE | ||||||||
| State: | WI | ||||||||
| PostalCode: | 535462343 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6083718000 | ||||||||
| FaxNumber: | 6083718907 | ||||||||
| Practice Location | |||||||||
| Address1: | 3200 E RACINE ST | ||||||||
| Address2: | |||||||||
| City: | JANESVILLE | ||||||||
| State: | WI | ||||||||
| PostalCode: | 535462343 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6083718000 | ||||||||
| FaxNumber: | 6083718907 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/07/2021 | ||||||||
| LastUpdateDate: | 06/30/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 06/30/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 152W00000X | 3679-35 | WI | Y | Eye and Vision Services Providers | Optometrist |
ID Information
| ID | Type | State | Issuer | Description | 1710554019 | 05 | WI | MEDICAID |