=====================================================
General NPI Number Information
=====================================================
NPI Number | 1710705975
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | MALLORIE BETH LARIMORE OD
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/27/2024
-----------------------------------------------------
Last Update Date | 04/21/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 8215 S MINGO RD STE 100
-----------------------------------------------------
City | TULSA
-----------------------------------------------------
State | OK
-----------------------------------------------------
Zip | 74133-4671
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 918-252-7432
-----------------------------------------------------
Fax | 918-250-9003
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1601 S 4TH ST
-----------------------------------------------------
City | BROKEN ARROW
-----------------------------------------------------
State | OK
-----------------------------------------------------
Zip | 74012-5655
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 405-509-4913
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 152W00000X
-----------------------------------------------------
Taxonomy Name | Optometrist
-----------------------------------------------------
License Number | 3268
-----------------------------------------------------
License Number State | OK
-----------------------------------------------------