Provider Demographics
NPI:1851132609
Name:SIMKIN, LARISSA MEREDITH (OD)
Entity type:Individual
Prefix:
First Name:LARISSA
Middle Name:MEREDITH
Last Name:SIMKIN
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:138 OYAMA RD
Mailing Address - Street 2:
Mailing Address - City:SUMMERVILLE
Mailing Address - State:SC
Mailing Address - Zip Code:29486-6977
Mailing Address - Country:US
Mailing Address - Phone:720-218-4690
Mailing Address - Fax:
Practice Address - Street 1:2007 2ND AVE STE 2
Practice Address - Street 2:
Practice Address - City:SUMMERVILLE
Practice Address - State:SC
Practice Address - Zip Code:29486-7888
Practice Address - Country:US
Practice Address - Phone:843-873-1889
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-06-05
Last Update Date:2024-06-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC2484152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist