Provider Demographics
NPI:1417020512
Name:LUND, LARRY A (OD)
Entity Type:Individual
Prefix:DR
First Name:LARRY
Middle Name:A
Last Name:LUND
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 1:205 G ST
Mailing Address - Street 2:
Mailing Address - City:SALIDA
Mailing Address - State:CO
Mailing Address - Zip Code:81201-2018
Mailing Address - Country:US
Mailing Address - Phone:719-539-2519
Mailing Address - Fax:719-539-7327
Practice Address - Street 1:205 G ST
Practice Address - Street 2:
Practice Address - City:SALIDA
Practice Address - State:CO
Practice Address - Zip Code:81201-2018
Practice Address - Country:US
Practice Address - Phone:719-539-2519
Practice Address - Fax:719-539-7327
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-16
Last Update Date:2009-08-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO9985699152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
COU29821Medicare UPIN
COC77213Medicare PIN
CO0932500001Medicare NSC