Provider Demographics
NPI:1033248901
Name:PRATT, LARRY F (OD)
Entity Type:Individual
Prefix:
First Name:LARRY
Middle Name:F
Last Name:PRATT
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:PO BOX 676
Mailing Address - Street 2:
Mailing Address - City:AURORA
Mailing Address - State:MO
Mailing Address - Zip Code:65605-0676
Mailing Address - Country:US
Mailing Address - Phone:417-678-2161
Mailing Address - Fax:417-678-2241
Practice Address - Street 1:930 S ELLIOTT AVE
Practice Address - Street 2:
Practice Address - City:AURORA
Practice Address - State:MO
Practice Address - Zip Code:65605-2402
Practice Address - Country:US
Practice Address - Phone:417-678-2161
Practice Address - Fax:417-678-2241
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-05
Last Update Date:2013-04-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MOT02302152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO310574918Medicaid
MO310574918Medicaid
0186170001Medicare NSC