Provider Demographics
NPI:1902808561
Name:TAGTMEYER, LARRY L (OD)
Entity Type:Individual
Prefix:DR
First Name:LARRY
Middle Name:L
Last Name:TAGTMEYER
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2504 W 15TH AVE
Mailing Address - Street 2:
Mailing Address - City:EMPORIA
Mailing Address - State:KS
Mailing Address - Zip Code:66801-6102
Mailing Address - Country:US
Mailing Address - Phone:620-342-7054
Mailing Address - Fax:620-342-8203
Practice Address - Street 1:2504 W 15TH AVE
Practice Address - Street 2:
Practice Address - City:EMPORIA
Practice Address - State:KS
Practice Address - Zip Code:66801-6102
Practice Address - Country:US
Practice Address - Phone:620-342-7054
Practice Address - Fax:620-342-8203
Is Sole Proprietor?:No
Enumeration Date:2005-08-12
Last Update Date:2008-08-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS1042-3152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
410014645OtherRAILROAD MEDICARE
KS100091020BMedicaid
0279700001OtherCIGNA DMERC
410014645OtherRAILROAD MEDICARE
KS100091020BMedicaid
KS049820Medicare PIN