Provider Demographics
NPI:1417066622
Name:MAGNUSON, LARRY M (OD)
Entity Type:Individual
Prefix:DR
First Name:LARRY
Middle Name:M
Last Name:MAGNUSON
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:PO BOX 309
Mailing Address - Street 2:
Mailing Address - City:WAYNE
Mailing Address - State:NE
Mailing Address - Zip Code:68787-0309
Mailing Address - Country:US
Mailing Address - Phone:402-375-5160
Mailing Address - Fax:402-375-3302
Practice Address - Street 1:215 W 2ND ST
Practice Address - Street 2:
Practice Address - City:WAYNE
Practice Address - State:NE
Practice Address - Zip Code:68787-1842
Practice Address - Country:US
Practice Address - Phone:402-375-5160
Practice Address - Fax:402-375-3302
Is Sole Proprietor?:No
Enumeration Date:2006-08-30
Last Update Date:2012-06-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE877152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NE10025560300Medicaid
NE6683330001Medicare NSC
NET40318Medicare UPIN
NENA2076001Medicare PIN