Provider Demographics
NPI:1265431340
Name:GUNNELL, LARRY D (OD)
Entity type:Individual
Prefix:
First Name:LARRY
Middle Name:D
Last Name:GUNNELL
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 1:3631 MAPLEWOOD AVE
Mailing Address - Street 2:SUITE 2
Mailing Address - City:WICHITA FALLS
Mailing Address - State:TX
Mailing Address - Zip Code:76308-2149
Mailing Address - Country:US
Mailing Address - Phone:940-696-0296
Mailing Address - Fax:940-696-0298
Practice Address - Street 1:3631 MAPLEWOOD AVE
Practice Address - Street 2:SUITE 2
Practice Address - City:WICHITA FALLS
Practice Address - State:TX
Practice Address - Zip Code:76308-2149
Practice Address - Country:US
Practice Address - Phone:940-696-0296
Practice Address - Fax:940-696-0298
Is Sole Proprietor?:Yes
Enumeration Date:2005-07-20
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX2496TG152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX0930265-02Medicaid
TX2496TGOtherTEXAS OPTOMETRY BOARD
TX2496TGOtherTEXAS OPTOMETRY BOARD
TX2496TGOtherTEXAS OPTOMETRY BOARD
TX0930265-02Medicaid
TX00E04D0Medicare PIN