Provider Demographics
NPI:1225207202
Name:HALL, LARRY JENE (MD)
Entity Type:Individual
Prefix:DR
First Name:LARRY
Middle Name:JENE
Last Name:HALL
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 1:457 LONE ROCK RD
Mailing Address - Street 2:
Mailing Address - City:GLIDE
Mailing Address - State:OR
Mailing Address - Zip Code:97443-9779
Mailing Address - Country:US
Mailing Address - Phone:541-496-4546
Mailing Address - Fax:541-496-4625
Practice Address - Street 1:2010 OPPORTUNITY LANE
Practice Address - Street 2:
Practice Address - City:GLIDE
Practice Address - State:OR
Practice Address - Zip Code:97443-9779
Practice Address - Country:US
Practice Address - Phone:541-496-4546
Practice Address - Fax:541-496-8538
Is Sole Proprietor?:No
Enumeration Date:2008-02-25
Last Update Date:2008-02-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR6527208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR080796Medicaid