MEDICARE: DR. LARRY D. MALASHOCK O.D.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	152W00000X	Optometrist	920	NE

General Provider Information

NPI Number	:	1962402214
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. LARRY D. MALASHOCK O.D.

Provider Business Mailing Address
First Line	:	2445 BROADWAY ST
Second Line	:
City	:	QUINCY
State	:	IL
Zip	:	62301-3257
Country	:	US
Telephone Number	:	217-228-6313
Fax Number	:	217-641-0028

Provider Business Practice Location Address
First Line	:	2545 S 132ND ST
Second Line	:
City	:	OMAHA
State	:	NE
Zip	:	68144-2532
Country	:	US
Telephone Number	:	402-330-4330
Fax Number	:	402-330-6134

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	07/28/2005
Last Update Date	:	12/28/2017

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