Provider Demographics
NPI:1295748903
Name:MALICKY, LARRY E (OD FAAO)
Entity type:Individual
Prefix:DR
First Name:LARRY
Middle Name:E
Last Name:MALICKY
Suffix:
Gender:M
Credentials:OD FAAO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:566 S QUAIL LANE
Mailing Address - Street 2:
Mailing Address - City:COLUMBUS
Mailing Address - State:NE
Mailing Address - Zip Code:68601-6308
Mailing Address - Country:US
Mailing Address - Phone:402-908-4787
Mailing Address - Fax:
Practice Address - Street 1:566 S QUAIL LN
Practice Address - Street 2:
Practice Address - City:COLUMBUS
Practice Address - State:NE
Practice Address - Zip Code:68601-6308
Practice Address - Country:US
Practice Address - Phone:402-561-0545
Practice Address - Fax:402-564-0078
Is Sole Proprietor?:No
Enumeration Date:2006-08-14
Last Update Date:2008-10-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE801152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NE47055862700Medicaid
NEN001920OtherCHAMPUS
NE06731OtherBC
NE47055862700Medicaid
NE0313770001Medicare NSC
NEN001920OtherCHAMPUS