Provider Demographics
NPI:1689889503
Name:GRACE, LARRY J (OD)
Entity Type:Individual
Prefix:DR
First Name:LARRY
Middle Name:J
Last Name:GRACE
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 1944
Mailing Address - Street 2:
Mailing Address - City:FORT SMITH
Mailing Address - State:AR
Mailing Address - Zip Code:72902-1944
Mailing Address - Country:US
Mailing Address - Phone:479-782-5057
Mailing Address - Fax:
Practice Address - Street 1:2000 DODSON AVE
Practice Address - Street 2:
Practice Address - City:FORT SMITH
Practice Address - State:AR
Practice Address - Zip Code:72901-4824
Practice Address - Country:US
Practice Address - Phone:479-782-5057
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-14
Last Update Date:2008-03-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AR2071152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
0226810001Medicare NSC
T20265Medicare UPIN
AR49025Medicare ID - Type Unspecified