Provider Demographics
NPI:1104880129
Name:FABIAN, LARRY R (OD)
Entity type:Individual
Prefix:DR
First Name:LARRY
Middle Name:R
Last Name:FABIAN
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
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Mailing Address - Street 1:18660 VISTA DE ALMADEN
Mailing Address - Street 2:
Mailing Address - City:SAN JOSE
Mailing Address - State:CA
Mailing Address - Zip Code:95120
Mailing Address - Country:US
Mailing Address - Phone:408-268-7621
Mailing Address - Fax:408-268-7621
Practice Address - Street 1:1817 HAMILTON AVE
Practice Address - Street 2:
Practice Address - City:SAN JOSE
Practice Address - State:CA
Practice Address - Zip Code:95125
Practice Address - Country:US
Practice Address - Phone:408-264-1555
Practice Address - Fax:408-264-1562
Is Sole Proprietor?:No
Enumeration Date:2006-04-14
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
CAOPT 6909 TPL152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
T10437Medicare UPIN
S00069090Medicare ID - Type Unspecified