Provider Demographics
NPI:1497846877
Name:ALLEN, LARRY JAMES (OD)
Entity Type:Individual
Prefix:
First Name:LARRY
Middle Name:JAMES
Last Name:ALLEN
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 680317
Mailing Address - Street 2:
Mailing Address - City:FORT PAYNE
Mailing Address - State:AL
Mailing Address - Zip Code:35968-1604
Mailing Address - Country:US
Mailing Address - Phone:256-845-0231
Mailing Address - Fax:
Practice Address - Street 1:103 GRAND AVE SW
Practice Address - Street 2:
Practice Address - City:FORT PAYNE
Practice Address - State:AL
Practice Address - Zip Code:35967-1915
Practice Address - Country:US
Practice Address - Phone:256-845-0231
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-28
Last Update Date:2008-06-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ALS 494 TA 004152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL000059724Medicaid
AL51059724OtherBCBS OF ALABAMA
AL0739480001Medicare NSC
AL000059724Medicare PIN
AL51059724OtherBCBS OF ALABAMA