Provider Demographics
NPI:1104849264
Name:PERRY, LARRY ELBERT (MD)
Entity Type:Individual
Prefix:
First Name:LARRY
Middle Name:ELBERT
Last Name:PERRY
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:PO BOX 5118
Mailing Address - Street 2:
Mailing Address - City:ONEIDA
Mailing Address - State:TN
Mailing Address - Zip Code:37841-5118
Mailing Address - Country:US
Mailing Address - Phone:423-569-8840
Mailing Address - Fax:423-569-2533
Practice Address - Street 1:20405 ALBERTA ST
Practice Address - Street 2:
Practice Address - City:ONEIDA
Practice Address - State:TN
Practice Address - Zip Code:37841-3509
Practice Address - Country:US
Practice Address - Phone:423-569-8840
Practice Address - Fax:423-569-2533
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-26
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNMD0000031532208D00000X
KY35454208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN3061062Medicaid
KY64799612Medicaid
TN3061062Medicare ID - Type Unspecified
TN3061062Medicaid