Provider Demographics
NPI:1659864395
Name:KATHRYN LARSSON, O.D.
Entity Type:Organization
Organization Name:KATHRYN LARSSON, O.D.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OPTOMETRIST/ OWNER
Authorized Official - Prefix:
Authorized Official - First Name:KATHRYN
Authorized Official - Middle Name:
Authorized Official - Last Name:LARSSON
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:209-526-9883
Mailing Address - Street 1:1150 W ORANGEBURG AVE
Mailing Address - Street 2:
Mailing Address - City:MODESTO
Mailing Address - State:CA
Mailing Address - Zip Code:95350-4042
Mailing Address - Country:US
Mailing Address - Phone:209-526-9883
Mailing Address - Fax:209-526-8681
Practice Address - Street 1:1150 W ORANGEBURG AVE
Practice Address - Street 2:
Practice Address - City:MODESTO
Practice Address - State:CA
Practice Address - Zip Code:95350-4042
Practice Address - Country:US
Practice Address - Phone:209-526-9883
Practice Address - Fax:209-526-8681
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-06-07
Last Update Date:2018-06-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA9225T261QS0132X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QS0132XAmbulatory Health Care FacilitiesClinic/CenterOphthalmologic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA6012490001Medicaid