Provider Demographics
NPI:1265629729
Name:WASHBURN, LARRY L (OD)
Entity type:Individual
Prefix:
First Name:LARRY
Middle Name:L
Last Name:WASHBURN
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:PO BOX 747
Mailing Address - Street 2:505 N FRANKLIN AVE
Mailing Address - City:COLBY
Mailing Address - State:KS
Mailing Address - Zip Code:67701-0747
Mailing Address - Country:US
Mailing Address - Phone:785-462-3348
Mailing Address - Fax:785-462-3599
Practice Address - Street 1:505 N FRANKLIN AVE
Practice Address - Street 2:STE B
Practice Address - City:COLBY
Practice Address - State:KS
Practice Address - Zip Code:67701-2356
Practice Address - Country:US
Practice Address - Phone:785-462-3348
Practice Address - Fax:785-462-3599
Is Sole Proprietor?:Yes
Enumeration Date:2007-09-28
Last Update Date:2008-11-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS1111-3152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
KS100090170AMedicaid
KS100090170AMedicaid
KST43673Medicare UPIN