Provider Demographics
NPI:1053313338
Name:NICHOLSON, LARRY LEE II (OD)
Entity type:Individual
Prefix:DR
First Name:LARRY
Middle Name:LEE
Last Name:NICHOLSON
Suffix:II
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 1:19870 MAIN E ST
Mailing Address - Street 2:
Mailing Address - City:HUNTINGDON
Mailing Address - State:TN
Mailing Address - Zip Code:38344-3927
Mailing Address - Country:US
Mailing Address - Phone:731-986-4400
Mailing Address - Fax:731-986-7981
Practice Address - Street 1:19870 MAIN E ST
Practice Address - Street 2:
Practice Address - City:HUNTINGDON
Practice Address - State:TN
Practice Address - Zip Code:38344-3927
Practice Address - Country:US
Practice Address - Phone:731-986-4400
Practice Address - Fax:731-986-7981
Is Sole Proprietor?:No
Enumeration Date:2005-06-01
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNODT2544152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN0381350001OtherDMERC #
TN32920OtherMEMPHIS MGED CARE- TLC
TN621149225SCA1OtherHEALTH PARTNERS
TN3946177Medicaid
TN4086613OtherBCBS
TNP00137806OtherRAILROAD MEDICARE
TNP00137806OtherRAILROAD MEDICARE
TNP00137806OtherRAILROAD MEDICARE
TN621149225SCA1OtherHEALTH PARTNERS