Provider Demographics
NPI:1053352047
Name:RILEY, LARRY A (OD)
Entity type:Individual
Prefix:MR
First Name:LARRY
Middle Name:A
Last Name:RILEY
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 1:1402 N SIOUX AVE
Mailing Address - Street 2:
Mailing Address - City:CLAREMORE
Mailing Address - State:OK
Mailing Address - Zip Code:74017-3126
Mailing Address - Country:US
Mailing Address - Phone:918-341-3284
Mailing Address - Fax:918-341-3127
Practice Address - Street 1:1402 N SIOUX AVE
Practice Address - Street 2:
Practice Address - City:CLAREMORE
Practice Address - State:OK
Practice Address - Zip Code:74017-3126
Practice Address - Country:US
Practice Address - Phone:918-341-3284
Practice Address - Fax:918-341-3127
Is Sole Proprietor?:No
Enumeration Date:2006-06-09
Last Update Date:2017-01-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK966152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK100760520AMedicaid
OKP00442795OtherRAILROAD MEDICARE
OKT40622Medicare UPIN
OK100760520AMedicaid
OK233729101Medicare PIN