Provider Demographics
NPI:1780767152
Name:LARSON, LEONARD G (OD)
Entity type:Individual
Prefix:DR
First Name:LEONARD
Middle Name:G
Last Name:LARSON
Suffix:
Gender:M
Credentials:OD
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Mailing Address - Street 1:1950 OLD GALLOWS RD STE 520
Mailing Address - Street 2:
Mailing Address - City:VIENNA
Mailing Address - State:VA
Mailing Address - Zip Code:22182-3970
Mailing Address - Country:US
Mailing Address - Phone:703-847-8899
Mailing Address - Fax:866-795-4020
Practice Address - Street 1:869C JOHN MARSHALL HWY # C
Practice Address - Street 2:
Practice Address - City:FRONT ROYAL
Practice Address - State:VA
Practice Address - Zip Code:22630-4578
Practice Address - Country:US
Practice Address - Phone:540-635-3223
Practice Address - Fax:540-635-1050
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-21
Last Update Date:2018-01-24
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
VA0618000221152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist