Provider Demographics
NPI:1184674210
Name:LARRY WAMPLER DO PC
Entity Type:Organization
Organization Name:LARRY WAMPLER DO PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:LARRY
Authorized Official - Middle Name:R
Authorized Official - Last Name:WAMPLER
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:541-758-5047
Mailing Address - Street 1:PO BOX 932
Mailing Address - Street 2:
Mailing Address - City:CORVALLIS
Mailing Address - State:OR
Mailing Address - Zip Code:97339-0932
Mailing Address - Country:US
Mailing Address - Phone:541-758-5047
Mailing Address - Fax:541-758-3713
Practice Address - Street 1:930 SW ABBEY ST
Practice Address - Street 2:
Practice Address - City:NEWPORT
Practice Address - State:OR
Practice Address - Zip Code:97365-4820
Practice Address - Country:US
Practice Address - Phone:541-265-2244
Practice Address - Fax:541-574-2858
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-11
Last Update Date:2008-05-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR118792085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic RadiologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR230987Medicaid
ORE44215Medicare UPIN
OR230987Medicaid