Provider Demographics
NPI:1508869298
Name:CARR, LARRY WAYNE (OD)
Entity Type:Individual
Prefix:DR
First Name:LARRY
Middle Name:WAYNE
Last Name:CARR
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 1:416 S BRADFIELD DR
Mailing Address - Street 2:
Mailing Address - City:SAINT MARYS
Mailing Address - State:WV
Mailing Address - Zip Code:26170-9771
Mailing Address - Country:US
Mailing Address - Phone:304-684-9594
Mailing Address - Fax:
Practice Address - Street 1:214 WASHINGTON ST
Practice Address - Street 2:
Practice Address - City:SAINT MARYS
Practice Address - State:WV
Practice Address - Zip Code:26170-1041
Practice Address - Country:US
Practice Address - Phone:304-684-2491
Practice Address - Fax:304-684-2492
Is Sole Proprietor?:No
Enumeration Date:2005-05-27
Last Update Date:2007-10-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WVWV723OD152WP0200X, 152WC0802X, 152WS0006X, 152WX0102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152WX0102XEye and Vision Services ProvidersOptometristOccupational Vision
No152WP0200XEye and Vision Services ProvidersOptometristPediatrics
No152WC0802XEye and Vision Services ProvidersOptometristCorneal and Contact Management
No152WS0006XEye and Vision Services ProvidersOptometristSports Vision
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV0149409000Medicaid
WVT32589Medicare UPIN
WV4215681Medicare PIN