Basic Information
| Provider Information | |||||||||
| NPI: | 1700243458 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | DR. ALAN C. LARSEN, OPTOMETRIST, P.L.L.C. | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | |||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | 2705 SHERWOOD WAY | ||||||||
| Address2: | |||||||||
| City: | SAN ANGELO | ||||||||
| State: | TX | ||||||||
| PostalCode: | 769013091 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3259495750 | ||||||||
| FaxNumber: | 3252278254 | ||||||||
| Practice Location | |||||||||
| Address1: | 2705 SHERWOOD WAY | ||||||||
| Address2: | |||||||||
| City: | SAN ANGELO | ||||||||
| State: | TX | ||||||||
| PostalCode: | 769013091 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3259495750 | ||||||||
| FaxNumber: | 3252278254 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/26/2016 | ||||||||
| LastUpdateDate: | 10/23/2020 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | LARSEN | ||||||||
| AuthorizedOfficialFirstName: | ALAN | ||||||||
| AuthorizedOfficialMiddleName: | C | ||||||||
| AuthorizedOfficialTitleorPosition: | OPTOMETRIST, OWNER | ||||||||
| AuthorizedOfficialTelephone: | 3259495750 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | OD | ||||||||
| NPICertificationDate: | 10/23/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 152W00000X | 3962-TG | TX | Y | 193400000X SINGLE SPECIALTY GROUP | Eye and Vision Services Providers | Optometrist |
ID Information
| ID | Type | State | Issuer | Description | 093364001 | 05 | TX | MEDICAID |