Provider Demographics
NPI:1295826220
Name:LARRY N LONDON OD PC
Entity type:Organization
Organization Name:LARRY N LONDON OD PC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:RUSSELL
Authorized Official - Middle Name:
Authorized Official - Last Name:BEACH
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:703-522-3454
Mailing Address - Street 1:3800 FAIRFAX DR STE 1
Mailing Address - Street 2:
Mailing Address - City:ARLINGTON
Mailing Address - State:VA
Mailing Address - Zip Code:22203-1703
Mailing Address - Country:US
Mailing Address - Phone:703-522-3454
Mailing Address - Fax:703-522-9636
Practice Address - Street 1:3800 FAIRFAX DR STE 1
Practice Address - Street 2:
Practice Address - City:ARLINGTON
Practice Address - State:VA
Practice Address - Zip Code:22203-1703
Practice Address - Country:US
Practice Address - Phone:703-522-3454
Practice Address - Fax:703-522-9636
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-27
Last Update Date:2024-07-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0618000084152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
VACH7060Medicare PIN
VA799049Medicare PIN
VA799049Medicare PIN