Provider Demographics
NPI:1194031427
Name:LARRY SIMPFENDERFER OD INC
Entity Type:Organization
Organization Name:LARRY SIMPFENDERFER OD INC
Other - Org Name:ADVANCED OPTOMETRY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:LARRY
Authorized Official - Middle Name:JAMES
Authorized Official - Last Name:SIMPFENDERFER
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:209-334-2626
Mailing Address - Street 1:1210 W TOKAY ST
Mailing Address - Street 2:
Mailing Address - City:LODI
Mailing Address - State:CA
Mailing Address - Zip Code:95240-3810
Mailing Address - Country:US
Mailing Address - Phone:209-334-2626
Mailing Address - Fax:209-334-0710
Practice Address - Street 1:1210 W TOKAY ST
Practice Address - Street 2:
Practice Address - City:LODI
Practice Address - State:CA
Practice Address - Zip Code:95240-3810
Practice Address - Country:US
Practice Address - Phone:209-334-2626
Practice Address - Fax:209-334-0710
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-08-24
Last Update Date:2011-09-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAOPT7804TPL152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA1194031427Medicare NSC