Provider Demographics
NPI:1437133188
Name:LARSON, LARRANCE EDWIN (OD)
Entity Type:Individual
Prefix:DR
First Name:LARRANCE
Middle Name:EDWIN
Last Name:LARSON
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 1:5959 GREENBACK LN
Mailing Address - Street 2:STE 130
Mailing Address - City:CITRUS HEIGHTS
Mailing Address - State:CA
Mailing Address - Zip Code:95621-4700
Mailing Address - Country:US
Mailing Address - Phone:916-726-1818
Mailing Address - Fax:916-676-1029
Practice Address - Street 1:421 BLUE RAVINE RD
Practice Address - Street 2:STE 300
Practice Address - City:FOLSOM
Practice Address - State:CA
Practice Address - Zip Code:95630-3821
Practice Address - Country:US
Practice Address - Phone:916-983-1066
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-12-05
Last Update Date:2020-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA6725T152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAU20304Medicare UPIN
CASD0067250Medicare ID - Type Unspecified