Provider Demographics
NPI:1902947179
Name:SIMPFENDERFER, LARRY JAMES (OD)
Entity Type:Individual
Prefix:MR
First Name:LARRY
Middle Name:JAMES
Last Name:SIMPFENDERFER
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 1:1210 W TOKAY ST
Mailing Address - Street 2:
Mailing Address - City:LODI
Mailing Address - State:CA
Mailing Address - Zip Code:95240-3810
Mailing Address - Country:US
Mailing Address - Phone:209-334-2626
Mailing Address - Fax:209-334-0710
Practice Address - Street 1:1210 W TOKAY ST
Practice Address - Street 2:
Practice Address - City:LODI
Practice Address - State:CA
Practice Address - Zip Code:95240-3810
Practice Address - Country:US
Practice Address - Phone:209-334-2626
Practice Address - Fax:209-334-0710
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-09
Last Update Date:2008-04-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAOPT7804TPL152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CASD0078040Medicaid
CA0404070002Medicare NSC
CASD0078040Medicaid