Provider Demographics
NPI:1316154743
Name:SMITH, LARRY JOHN (ABO)
Entity type:Individual
Prefix:MR
First Name:LARRY
Middle Name:JOHN
Last Name:SMITH
Suffix:
Gender:M
Credentials:ABO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:351 HOSPITAL RD STE 100
Mailing Address - Street 2:
Mailing Address - City:NEWPORT BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:92663-3503
Mailing Address - Country:US
Mailing Address - Phone:949-645-2020
Mailing Address - Fax:949-645-3311
Practice Address - Street 1:351 HOSPITAL RD STE 100
Practice Address - Street 2:
Practice Address - City:NEWPORT BEACH
Practice Address - State:CA
Practice Address - Zip Code:92663-3503
Practice Address - Country:US
Practice Address - Phone:949-645-2020
Practice Address - Fax:949-645-3311
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-16
Last Update Date:2008-03-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CADL284156FX1800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes156FX1800XEye and Vision Services ProvidersTechnician/TechnologistOptician