Provider Demographics
NPI:1164402046
Name:MCINTIRE, LARRY DOUGLAS (DO)
Entity Type:Individual
Prefix:
First Name:LARRY
Middle Name:DOUGLAS
Last Name:MCINTIRE
Suffix:
Gender:M
Credentials:DO
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 3810
Mailing Address - Street 2:
Mailing Address - City:JOPLIN
Mailing Address - State:MO
Mailing Address - Zip Code:64803-3810
Mailing Address - Country:US
Mailing Address - Phone:417-347-6767
Mailing Address - Fax:417-347-3170
Practice Address - Street 1:1331 W 32ND ST
Practice Address - Street 2:
Practice Address - City:JOPLIN
Practice Address - State:MO
Practice Address - Zip Code:64804
Practice Address - Country:US
Practice Address - Phone:417-347-6767
Practice Address - Fax:417-347-3170
Is Sole Proprietor?:No
Enumeration Date:2006-01-18
Last Update Date:2011-03-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO33563207YX0905X
KS0526146207YX0905X
OK22386207YX0905X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207YX0905XAllopathic & Osteopathic PhysiciansOtolaryngologyOtolaryngology/Facial Plastic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO241195528Medicaid
MO9054OtherBLUE CROSS
D41507Medicare UPIN
MO241195528Medicaid