Provider Demographics
NPI:1720196421
Name:LARSEN, LINDA RUSNOCK (OD)
Entity Type:Individual
Prefix:DR
First Name:LINDA
Middle Name:RUSNOCK
Last Name:LARSEN
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:29562 POND RIDGE RD
Mailing Address - Street 2:
Mailing Address - City:FARMINGTON HILLS
Mailing Address - State:MI
Mailing Address - Zip Code:48334-3031
Mailing Address - Country:US
Mailing Address - Phone:248-737-3923
Mailing Address - Fax:
Practice Address - Street 1:22250 PROVIDENCE DR
Practice Address - Street 2:SUITE 304
Practice Address - City:SOUTHFIELD
Practice Address - State:MI
Practice Address - Zip Code:48075-4825
Practice Address - Country:US
Practice Address - Phone:248-569-4366
Practice Address - Fax:248-569-4614
Is Sole Proprietor?:No
Enumeration Date:2006-08-25
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4901002714152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MIU54537Medicare UPIN
MIOM30440Medicare ID - Type Unspecified