Provider Demographics
NPI:1740287952
Name:BROTHERS, LARRY J (OD)
Entity type:Individual
Prefix:DR
First Name:LARRY
Middle Name:J
Last Name:BROTHERS
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 1:4777 SEAGRAVES DR
Mailing Address - Street 2:
Mailing Address - City:JOPLIN
Mailing Address - State:MO
Mailing Address - Zip Code:64804-5550
Mailing Address - Country:US
Mailing Address - Phone:417-782-1133
Mailing Address - Fax:
Practice Address - Street 1:2013 S JOPLIN AVE
Practice Address - Street 2:
Practice Address - City:JOPLIN
Practice Address - State:MO
Practice Address - Zip Code:64804-2033
Practice Address - Country:US
Practice Address - Phone:417-624-5005
Practice Address - Fax:417-624-5215
Is Sole Proprietor?:No
Enumeration Date:2005-07-01
Last Update Date:2008-01-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MOT02605152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO32594OtherBCBS
MO0399260001Medicare NSC
MO32594OtherBCBS