Provider Demographics
NPI:1255325049
Name:BISHOP, LARRY S (MD)
Entity Type:Individual
Prefix:
First Name:LARRY
Middle Name:S
Last Name:BISHOP
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 1:3300 S FISKE BLVD
Mailing Address - Street 2:
Mailing Address - City:ROCKLEDGE
Mailing Address - State:FL
Mailing Address - Zip Code:32955-4306
Mailing Address - Country:US
Mailing Address - Phone:321-361-5606
Mailing Address - Fax:321-951-7408
Practice Address - Street 1:7125 MURRELL RD
Practice Address - Street 2:
Practice Address - City:MELBOURNE
Practice Address - State:FL
Practice Address - Zip Code:32940-7999
Practice Address - Country:US
Practice Address - Phone:321-242-8790
Practice Address - Fax:321-751-9362
Is Sole Proprietor?:No
Enumeration Date:2005-09-07
Last Update Date:2020-06-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME67730207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatology
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL27194WOtherMEDICARE
FL378803200Medicaid
FLG08054Medicare UPIN
27194YMedicare PIN