Provider Demographics
NPI:1235167636
Name:LARTER, ROLAND ROY (MD)
Entity Type:Individual
Prefix:
First Name:ROLAND
Middle Name:ROY
Last Name:LARTER
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 1:1010 S BIRCH AVE
Mailing Address - Street 2:P.O. BOX 700
Mailing Address - City:HALLOCK
Mailing Address - State:MN
Mailing Address - Zip Code:56728-4215
Mailing Address - Country:US
Mailing Address - Phone:218-843-2868
Mailing Address - Fax:
Practice Address - Street 1:1010 S BIRCH AVE
Practice Address - Street 2:
Practice Address - City:HALLOCK
Practice Address - State:MN
Practice Address - Zip Code:56728-4215
Practice Address - Country:US
Practice Address - Phone:218-843-2868
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-28
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN17741207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN17741OtherMD LICENSE
MN17741OtherMD LICENSE