Provider Demographics
NPI:1972685089
Name:LARSEN, WAYNE THOMAS (OD)
Entity Type:Individual
Prefix:DR
First Name:WAYNE
Middle Name:THOMAS
Last Name:LARSEN
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 1:28356 S WESTERN AVE
Mailing Address - Street 2:
Mailing Address - City:RANCHO PALOS VERDES
Mailing Address - State:CA
Mailing Address - Zip Code:90275-1434
Mailing Address - Country:US
Mailing Address - Phone:310-547-2685
Mailing Address - Fax:310-547-1527
Practice Address - Street 1:28356 S WESTERN AVE
Practice Address - Street 2:
Practice Address - City:RANCHO PALOS VERDES
Practice Address - State:CA
Practice Address - Zip Code:90275-1434
Practice Address - Country:US
Practice Address - Phone:310-547-2685
Practice Address - Fax:310-547-1527
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-19
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAOPT5169TPL152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAT09891Medicare UPIN