Provider Demographics
NPI:1225390362
Name:MEDOLO, LARRY
Entity Type:Individual
Prefix:
First Name:LARRY
Middle Name:
Last Name:MEDOLO
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:184 PLEASANT VALLEY ST STE 1-204
Mailing Address - Street 2:
Mailing Address - City:METHUEN
Mailing Address - State:MA
Mailing Address - Zip Code:01844-5855
Mailing Address - Country:US
Mailing Address - Phone:978-935-1390
Mailing Address - Fax:978-737-3510
Practice Address - Street 1:184 PLEASANT VALLEY ST STE 1-204
Practice Address - Street 2:
Practice Address - City:METHUEN
Practice Address - State:MA
Practice Address - Zip Code:01844-5855
Practice Address - Country:US
Practice Address - Phone:978-935-1390
Practice Address - Fax:978-737-3510
Is Sole Proprietor?:Yes
Enumeration Date:2012-06-14
Last Update Date:2021-09-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA959159175L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes175L00000XOther Service ProvidersHomeopath