Provider Demographics
NPI:1770593295
Name:LARRY J LATOUR OD PA
Entity type:Organization
Organization Name:LARRY J LATOUR OD PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OPTOMETRIST PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:LARRY
Authorized Official - Middle Name:J
Authorized Official - Last Name:LATOUR
Authorized Official - Suffix:
Authorized Official - Credentials:OD PA
Authorized Official - Phone:386-462-7772
Mailing Address - Street 1:PO BOX 2170
Mailing Address - Street 2:
Mailing Address - City:ALACHUA
Mailing Address - State:FL
Mailing Address - Zip Code:32616
Mailing Address - Country:US
Mailing Address - Phone:386-462-7772
Mailing Address - Fax:386-462-1122
Practice Address - Street 1:15551 NW 441 UNIT 110
Practice Address - Street 2:
Practice Address - City:ALACHUA
Practice Address - State:FL
Practice Address - Zip Code:32616
Practice Address - Country:US
Practice Address - Phone:386-462-7772
Practice Address - Fax:386-462-1122
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-08
Last Update Date:2012-10-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOPC0001543152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL078166500Medicaid
FL19670BMedicare ID - Type Unspecified
FLFT190AMedicare PIN
FL078166500Medicaid
FL19670ZMedicare PIN