Healthcare Provider Details

I. General information

NPI: 1780767152
Provider Name (Legal Business Name): LEONARD G LARSON O.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/21/2006
Last Update Date: 01/24/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

869C JOHN MARSHALL HWY # C
FRONT ROYAL VA
22630-4578
US

IV. Provider business mailing address

1950 OLD GALLOWS RD STE 520
VIENNA VA
22182-3970
US

V. Phone/Fax

Practice location:
  • Phone: 540-635-3223
  • Fax: 540-635-1050
Mailing address:
  • Phone: 703-847-8899
  • Fax: 866-795-4020

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number0618000221
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: