Provider Demographics
NPI:1831159169
Name:ELLINGSON, LARRY D (OD)
Entity type:Individual
Prefix:DR
First Name:LARRY
Middle Name:D
Last Name:ELLINGSON
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 1:4823 RAPID CREEK RD NE
Mailing Address - Street 2:
Mailing Address - City:IOWA CITY
Mailing Address - State:IA
Mailing Address - Zip Code:52240-7716
Mailing Address - Country:US
Mailing Address - Phone:319-643-2304
Mailing Address - Fax:
Practice Address - Street 1:1451 CORAL RIDGE AVE
Practice Address - Street 2:
Practice Address - City:CORALVILLE
Practice Address - State:IA
Practice Address - Zip Code:52241-2805
Practice Address - Country:US
Practice Address - Phone:319-466-0644
Practice Address - Fax:319-466-0330
Is Sole Proprietor?:Yes
Enumeration Date:2006-03-23
Last Update Date:2014-01-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA201431154152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA1259168Medicaid
IAT01400Medicare UPIN
IAI13144Medicare ID - Type Unspecified