Provider Demographics
NPI:1447216221
Name:DEDONATO, LARRY M (OD)
Entity Type:Individual
Prefix:DR
First Name:LARRY
Middle Name:M
Last Name:DEDONATO
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 1:1429 MAIN ST
Mailing Address - Street 2:
Mailing Address - City:DELANO
Mailing Address - State:CA
Mailing Address - Zip Code:93215-1726
Mailing Address - Country:US
Mailing Address - Phone:661-725-9771
Mailing Address - Fax:661-725-2403
Practice Address - Street 1:1429 MAIN ST
Practice Address - Street 2:
Practice Address - City:DELANO
Practice Address - State:CA
Practice Address - Zip Code:93215-1726
Practice Address - Country:US
Practice Address - Phone:661-725-9771
Practice Address - Fax:661-725-2403
Is Sole Proprietor?:Yes
Enumeration Date:2006-04-21
Last Update Date:2012-04-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAOPT6429T152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CASD0064290Medicaid
T10320Medicare UPIN
CASD0064290Medicaid