Provider Demographics
NPI:1932102894
Name:HENRY, LARRY RANDALL (OD)
Entity Type:Individual
Prefix:
First Name:LARRY
Middle Name:RANDALL
Last Name:HENRY
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 1:14701 N SANTA FE AVE
Mailing Address - Street 2:
Mailing Address - City:EDMOND
Mailing Address - State:OK
Mailing Address - Zip Code:73013-3411
Mailing Address - Country:US
Mailing Address - Phone:405-752-2733
Mailing Address - Fax:405-752-2172
Practice Address - Street 1:14701 N SANTA FE AVE
Practice Address - Street 2:
Practice Address - City:EDMOND
Practice Address - State:OK
Practice Address - Zip Code:73013-3411
Practice Address - Country:US
Practice Address - Phone:405-752-2733
Practice Address - Fax:405-752-2172
Is Sole Proprietor?:No
Enumeration Date:2005-05-24
Last Update Date:2008-05-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK2040152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK4628540OtherAETNA
OK1677321OtherUNITED HEALTHCARE
OK100765720AMedicaid
OK4628540OtherAETNA
OK410039951Medicare PIN
OK$$$$$$$$$MMedicare PIN