Provider Demographics
NPI:1841298445
Name:MORRISON, LARRY DONAVON (OD)
Entity type:Individual
Prefix:DR
First Name:LARRY
Middle Name:DONAVON
Last Name:MORRISON
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 1:785 SO HIGHWAY 59
Mailing Address - Street 2:P O BOX 339
Mailing Address - City:MAHNOMEN
Mailing Address - State:MN
Mailing Address - Zip Code:56557-5007
Mailing Address - Country:US
Mailing Address - Phone:218-936-2020
Mailing Address - Fax:218-935-5541
Practice Address - Street 1:785 S HIGHWAY 59
Practice Address - Street 2:
Practice Address - City:MAHNOMEN
Practice Address - State:MN
Practice Address - Zip Code:56557-5007
Practice Address - Country:US
Practice Address - Phone:218-936-2020
Practice Address - Fax:218-935-5541
Is Sole Proprietor?:Yes
Enumeration Date:2005-07-08
Last Update Date:2008-08-22
Deactivation Date:2006-03-15
Deactivation Code:
Reactivation Date:2006-07-07
Provider Licenses
StateLicense IDTaxonomies
MN1739152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
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MN553P1MOOtherBCBS
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MN0M036MOOtherZENITH ADMIN.LOCAL 49
MN410036752OtherPALMETTO GBA
MN483361046247OtherPREFERRED ONE
MN906223800Medicaid
MN411895571101OtherUNICARE
MN2229857OtherMEDICA
MN906223800Medicaid
MNT65893Medicare UPIN