Provider Demographics
NPI:1033193966
Name:PESNELL, LARKUS (MD)
Entity Type:Individual
Prefix:
First Name:LARKUS
Middle Name:
Last Name:PESNELL
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:117 S 2ND ST
Mailing Address - Street 2:PO BOX 497
Mailing Address - City:AUGUSTA
Mailing Address - State:AR
Mailing Address - Zip Code:72006-2309
Mailing Address - Country:US
Mailing Address - Phone:870-347-2534
Mailing Address - Fax:870-347-3492
Practice Address - Street 1:1127 MAIN ST
Practice Address - Street 2:
Practice Address - City:VILONIA
Practice Address - State:AR
Practice Address - Zip Code:72173-9525
Practice Address - Country:US
Practice Address - Phone:501-796-6740
Practice Address - Fax:501-796-6744
Is Sole Proprietor?:No
Enumeration Date:2005-12-05
Last Update Date:2018-01-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARC4135207L00000X
ARC-4135208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
No207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK100081520AMedicaid
AR106481001Medicaid
AR770119701OtherARKANSAS BREASTCARE
AR50064272Medicare PIN
AR54031Medicare PIN
B90473Medicare UPIN
AR106481001Medicaid
OK100081520AMedicaid