Provider Demographics
NPI:1962402214
Name:MALASHOCK, LARRY D (OD)
Entity type:Individual
Prefix:DR
First Name:LARRY
Middle Name:D
Last Name:MALASHOCK
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:2445 BROADWAY ST
Mailing Address - Street 2:
Mailing Address - City:QUINCY
Mailing Address - State:IL
Mailing Address - Zip Code:62301-3257
Mailing Address - Country:US
Mailing Address - Phone:217-228-6313
Mailing Address - Fax:217-641-0028
Practice Address - Street 1:2545 S 132ND ST
Practice Address - Street 2:
Practice Address - City:OMAHA
Practice Address - State:NE
Practice Address - Zip Code:68144-2532
Practice Address - Country:US
Practice Address - Phone:402-330-4330
Practice Address - Fax:402-330-6134
Is Sole Proprietor?:No
Enumeration Date:2005-07-28
Last Update Date:2017-12-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE920152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NE47048659406Medicaid
NE410016510Medicare PIN
NE263821Medicare PIN