Provider Demographics
NPI:1538508031
Name:LARSON, ANDREW (OD)
Entity Type:Individual
Prefix:
First Name:ANDREW
Middle Name:
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 1:4012 REDWOOD DR
Mailing Address - Street 2:
Mailing Address - City:BETHLEHEM
Mailing Address - State:PA
Mailing Address - Zip Code:18020-7664
Mailing Address - Country:US
Mailing Address - Phone:315-591-0252
Mailing Address - Fax:
Practice Address - Street 1:93 CONSTITUTION BLVD
Practice Address - Street 2:
Practice Address - City:KUTZTOWN
Practice Address - State:PA
Practice Address - Zip Code:19530-1724
Practice Address - Country:US
Practice Address - Phone:610-683-3888
Practice Address - Fax:610-683-3083
Is Sole Proprietor?:No
Enumeration Date:2013-06-18
Last Update Date:2023-10-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYTUV008019152W00000X
PAOEG003708152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist