Provider Demographics
NPI:1376670216
Name:CHISM, LARRY MICHAEL (OD)
Entity Type:Individual
Prefix:
First Name:LARRY
Middle Name:MICHAEL
Last Name:CHISM
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 1:136 SHELLEY DR
Mailing Address - Street 2:
Mailing Address - City:TYLER
Mailing Address - State:TX
Mailing Address - Zip Code:75701-8723
Mailing Address - Country:US
Mailing Address - Phone:903-561-8686
Mailing Address - Fax:906-581-1518
Practice Address - Street 1:136 SHELLEY DR
Practice Address - Street 2:
Practice Address - City:TYLER
Practice Address - State:TX
Practice Address - Zip Code:75701-8723
Practice Address - Country:US
Practice Address - Phone:903-561-8686
Practice Address - Fax:906-581-1518
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-27
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX02774TG152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX909986OtherBLOCK VISION
TX48849OtherDAVIS VISION
TX0390950001OtherPALMETTO GBA MEDICARE
TX08379OtherSPECTERA
TX552688OtherNVA
TX81381QOtherBLUECROSSBLUESHIELD
TX0390950001OtherPALMETTO GBA MEDICARE
TX48849OtherDAVIS VISION