Provider Demographics
NPI:1952413924
Name:HOLLE, LARRY (OD)
Entity Type:Individual
Prefix:
First Name:LARRY
Middle Name:
Last Name:HOLLE
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 1:11230 N TATUM BLVD
Mailing Address - Street 2:#100
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85028-1663
Mailing Address - Country:US
Mailing Address - Phone:602-263-0850
Mailing Address - Fax:602-266-5490
Practice Address - Street 1:11230 N TATUM BLVD
Practice Address - Street 2:#100
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85028-1663
Practice Address - Country:US
Practice Address - Phone:602-263-0850
Practice Address - Fax:602-266-5490
Is Sole Proprietor?:No
Enumeration Date:2006-08-31
Last Update Date:2012-12-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ102152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZT 41744Medicare UPIN
AZZ84900Medicare PIN