Provider Demographics
NPI:1740240852
Name:OLSEN, LARRY L (OD)
Entity Type:Individual
Prefix:DR
First Name:LARRY
Middle Name:L
Last Name:OLSEN
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 1:501 E 15TH ST
Mailing Address - Street 2:SUITE 101
Mailing Address - City:EDMOND
Mailing Address - State:OK
Mailing Address - Zip Code:73013-5043
Mailing Address - Country:US
Mailing Address - Phone:405-341-2062
Mailing Address - Fax:405-341-6553
Practice Address - Street 1:501 E 15TH ST
Practice Address - Street 2:SUITE 101
Practice Address - City:EDMOND
Practice Address - State:OK
Practice Address - Zip Code:73013-5043
Practice Address - Country:US
Practice Address - Phone:405-341-2062
Practice Address - Fax:405-341-6553
Is Sole Proprietor?:Yes
Enumeration Date:2006-03-23
Last Update Date:2008-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK881152W00000X, 332H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
No332H00000XSuppliersEyewear Supplier
Provider Identifiers
StateIdentifier IDID TypeIssuer
OKT40595Medicare UPIN
OK0648360001Medicare NSC
OK$$$$$$$$$Medicare PIN