Healthcare Provider Details

I. General information

NPI: 1932102894
Provider Name (Legal Business Name): LARRY RANDALL HENRY O.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/24/2005
Last Update Date: 05/08/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

14701 N SANTA FE AVE
EDMOND OK
73013-3411
US

IV. Provider business mailing address

14701 N SANTA FE AVE
EDMOND OK
73013-3411
US

V. Phone/Fax

Practice location:
  • Phone: 405-752-2733
  • Fax: 405-752-2172
Mailing address:
  • Phone: 405-752-2733
  • Fax: 405-752-2172

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number2040
License Number StateOK

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: