Provider Demographics
NPI:1164414322
Name:BONDERUD, LARRY JAMES (OD)
Entity Type:Individual
Prefix:DR
First Name:LARRY
Middle Name:JAMES
Last Name:BONDERUD
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 1:865 OILFIELD AVE
Mailing Address - Street 2:
Mailing Address - City:SHELBY
Mailing Address - State:MT
Mailing Address - Zip Code:59474-2702
Mailing Address - Country:US
Mailing Address - Phone:406-434-5196
Mailing Address - Fax:406-434-5197
Practice Address - Street 1:865 OILFIELD AVE
Practice Address - Street 2:
Practice Address - City:SHELBY
Practice Address - State:MT
Practice Address - Zip Code:59474-2702
Practice Address - Country:US
Practice Address - Phone:406-434-5196
Practice Address - Fax:406-434-5197
Is Sole Proprietor?:Yes
Enumeration Date:2005-08-15
Last Update Date:2010-05-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MT393152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MT25830OtherBC/BS PROVIDER #
MT410016078OtherRAILROAD PROVIDER #
MT393OtherSTATE TAX ID #
MTMSF0007633OtherMT STATE FUND PROVIDER #
MT0481389Medicaid
MT810378082001OtherEBMS PROVIDER #
MT000002583Medicare ID - Type UnspecifiedPROVIDER ID
MT0336270001Medicare NSC
MTT81761Medicare UPIN