Provider Demographics
NPI:1164715298
Name:SEGROVES, LARRY JOE (DO)
Entity Type:Individual
Prefix:DR
First Name:LARRY
Middle Name:JOE
Last Name:SEGROVES
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 1:12223 WINDCHILL WAY
Mailing Address - Street 2:
Mailing Address - City:FENTON
Mailing Address - State:MI
Mailing Address - Zip Code:48430-3510
Mailing Address - Country:US
Mailing Address - Phone:810-629-9828
Mailing Address - Fax:
Practice Address - Street 1:12223 WINDCHILL WAY
Practice Address - Street 2:
Practice Address - City:FENTON
Practice Address - State:MI
Practice Address - Zip Code:48430-3510
Practice Address - Country:US
Practice Address - Phone:810-629-9828
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-05-23
Last Update Date:2011-05-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5101006595208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice