Provider Demographics
NPI:1093775629
Name:REED, LARRY D (MD)
Entity Type:Individual
Prefix:
First Name:LARRY
Middle Name:D
Last Name:REED
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 1:36 GARDEN CTR
Mailing Address - Street 2:
Mailing Address - City:BROOMFIELD
Mailing Address - State:CO
Mailing Address - Zip Code:80020-1730
Mailing Address - Country:US
Mailing Address - Phone:303-465-0401
Mailing Address - Fax:303-438-1351
Practice Address - Street 1:400 MAPLE SUMMIT RD
Practice Address - Street 2:
Practice Address - City:JERSEYVILLE
Practice Address - State:IL
Practice Address - Zip Code:62052-2028
Practice Address - Country:US
Practice Address - Phone:618-498-6402
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-03-27
Last Update Date:2016-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL0360735862085R0202X
MOR2D522085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILIL4399005OtherMEDICARE
IL036073586-2Medicaid
IL036073586-1Medicaid
MO202107736Medicaid
IL300064675Medicare ID - Type UnspecifiedMEDICARE RAILROAD
IL036073586-2Medicaid
IL036073586-1Medicaid
ILIL4399005OtherMEDICARE