Provider Demographics
NPI:1720154339
Name:LARSEN, EDWIN K (OD)
Entity Type:Individual
Prefix:MR
First Name:EDWIN
Middle Name:K
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 1:1737 FIRST ST
Mailing Address - Street 2:
Mailing Address - City:NAPA
Mailing Address - State:CA
Mailing Address - Zip Code:94559
Mailing Address - Country:US
Mailing Address - Phone:707-226-5446
Mailing Address - Fax:707-226-3772
Practice Address - Street 1:1737 FIRST ST
Practice Address - Street 2:
Practice Address - City:NAPA
Practice Address - State:CA
Practice Address - Zip Code:94559
Practice Address - Country:US
Practice Address - Phone:707-226-5446
Practice Address - Fax:707-226-3772
Is Sole Proprietor?:No
Enumeration Date:2006-11-27
Last Update Date:2012-01-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAOPT 105050 TPA152WC0802X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152WC0802XEye and Vision Services ProvidersOptometristCorneal and Contact Management
Provider Identifiers
StateIdentifier IDID TypeIssuer
CASD01015051Medicaid
CASD01015051Medicaid
CASD0105051Medicare PIN