Provider Demographics
NPI:1689662058
Name:LARSEN, ALAN C (OD)
Entity Type:Individual
Prefix:
First Name:ALAN
Middle Name:C
Last Name:LARSEN
Suffix:
Gender:M
Credentials:OD
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Mailing Address - Street 1:1950 OLD GALLOWS RD STE 520
Mailing Address - Street 2:
Mailing Address - City:VIENNA
Mailing Address - State:VA
Mailing Address - Zip Code:22182-3970
Mailing Address - Country:US
Mailing Address - Phone:703-847-8899
Mailing Address - Fax:571-223-6780
Practice Address - Street 1:2705 SHERWOOD WAY
Practice Address - Street 2:
Practice Address - City:SAN ANGELO
Practice Address - State:TX
Practice Address - Zip Code:76901-3091
Practice Address - Country:US
Practice Address - Phone:325-949-5750
Practice Address - Fax:325-944-4082
Is Sole Proprietor?:Yes
Enumeration Date:2005-10-11
Last Update Date:2020-12-18
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
TX03962TG152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX0933640-01Medicaid
TX00E69AMedicare PIN