Provider Demographics
NPI:1073677506
Name:LARSON, ALAN (OD)
Entity Type:Individual
Prefix:
First Name:ALAN
Middle Name:
Last Name:LARSON
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:PO BOX 848448
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75284-8448
Mailing Address - Country:US
Mailing Address - Phone:210-340-3531
Mailing Address - Fax:210-524-6587
Practice Address - Street 1:733 MARQUETTE AVE
Practice Address - Street 2:SUITE 219
Practice Address - City:MINNEAPOLIS
Practice Address - State:MN
Practice Address - Zip Code:55402-2309
Practice Address - Country:US
Practice Address - Phone:612-332-6656
Practice Address - Fax:612-904-2438
Is Sole Proprietor?:No
Enumeration Date:2006-12-20
Last Update Date:2014-04-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN1901152W00000X, 152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN468723000Medicaid
MNH400109346Medicare UPIN