Healthcare Provider Details

I. General information

NPI: 1245255223
Provider Name (Legal Business Name): LARRY DOUGLAS SUMNER O.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/12/2006
Last Update Date: 12/19/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3400 E BAYAUD AVE SUITE 485
DENVER CO
80209-2926
US

IV. Provider business mailing address

3400 E BAYAUD AVE SUITE 485
DENVER CO
80209-2926
US

V. Phone/Fax

Practice location:
  • Phone: 303-321-1606
  • Fax: 303-321-0920
Mailing address:
  • Phone: 303-321-1606
  • Fax: 303-321-0920

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152WC0802X
TaxonomyCorneal and Contact Management Optometrist
License Number1582
License Number StateCO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: