Provider Demographics
NPI:1770503914
Name:KOVAL, LARRY A (OD)
Entity Type:Individual
Prefix:DR
First Name:LARRY
Middle Name:A
Last Name:KOVAL
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 1:1950 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:
Mailing Address - Fax:
Practice Address - Street 1:2705 N LEBANON ST STE 230
Practice Address - Street 2:
Practice Address - City:LEBANON
Practice Address - State:IN
Practice Address - Zip Code:46052-8627
Practice Address - Country:US
Practice Address - Phone:765-482-2066
Practice Address - Fax:765-482-4847
Is Sole Proprietor?:No
Enumeration Date:2006-07-20
Last Update Date:2021-12-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN18002079152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN201164040Medicaid
ININ1943008Medicare PIN
IN201164040Medicaid
IN224080CMedicare ID - Type Unspecified