Provider Demographics
NPI:1366583361
Name:HARRISON, LARRY (OD)
Entity type:Individual
Prefix:DR
First Name:LARRY
Middle Name:
Last Name:HARRISON
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 1:926A DIABLO AVE
Mailing Address - Street 2:#426
Mailing Address - City:NOVATO
Mailing Address - State:CA
Mailing Address - Zip Code:94947-4025
Mailing Address - Country:US
Mailing Address - Phone:510-928-0043
Mailing Address - Fax:
Practice Address - Street 1:634 SAN ANSELMO AVE
Practice Address - Street 2:
Practice Address - City:SAN ANSELMO
Practice Address - State:CA
Practice Address - Zip Code:94960-2666
Practice Address - Country:US
Practice Address - Phone:415-747-8191
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-11
Last Update Date:2012-05-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
HIOD 525152WC0802X
CA6044152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
No152WC0802XEye and Vision Services ProvidersOptometristCorneal and Contact Management
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAGA220AMedicare PIN
CAT10213Medicare UPIN