Healthcare Provider Details

I. General information

NPI: 1629068259
Provider Name (Legal Business Name): LARS A GENTRY OD
Entity Type: Individual
Gender: Male
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 10/25/2005
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1207 W MAIN ST
CARMI IL
62821-1388
US

IV. Provider business mailing address

1207 W MAIN ST
CARMI IL
62821-1388
US

V. Phone/Fax

Practice location:
  • Phone: 618-384-3411
  • Fax: 618-382-7226
Mailing address:
  • Phone: 618-384-3411
  • Fax: 618-382-7226

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: