Provider Demographics
NPI:1750487898
Name:OTWELL, LARRY EDWARD (OD)
Entity Type:Individual
Prefix:DR
First Name:LARRY
Middle Name:EDWARD
Last Name:OTWELL
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 1:977 BEL AIR DR
Mailing Address - Street 2:
Mailing Address - City:PALM SPRINGS
Mailing Address - State:CA
Mailing Address - Zip Code:92264-0663
Mailing Address - Country:US
Mailing Address - Phone:206-619-1230
Mailing Address - Fax:
Practice Address - Street 1:72840 CA-111 S
Practice Address - Street 2:SUITE F201
Practice Address - City:PALM DESERT
Practice Address - State:CA
Practice Address - Zip Code:92260
Practice Address - Country:US
Practice Address - Phone:760-848-0040
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-16
Last Update Date:2023-02-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA1735152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA2022259Medicaid
WAT79339Medicare UPIN
WA2022259Medicaid