Provider Demographics
NPI:1902234602
Name:LARSEN, COLETTE IRENE (OD)
Entity Type:Individual
Prefix:DR
First Name:COLETTE
Middle Name:IRENE
Last Name:LARSEN
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 1:2259 NOVA VILLAGE DR
Mailing Address - Street 2:
Mailing Address - City:DAVIE
Mailing Address - State:FL
Mailing Address - Zip Code:33317-7032
Mailing Address - Country:US
Mailing Address - Phone:908-892-4333
Mailing Address - Fax:
Practice Address - Street 1:11005 PINES BLVD STE 510
Practice Address - Street 2:
Practice Address - City:PEMBROKE PINES
Practice Address - State:FL
Practice Address - Zip Code:33026-5217
Practice Address - Country:US
Practice Address - Phone:954-248-5010
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-10-16
Last Update Date:2013-10-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOPC4837152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist