Provider Demographics
NPI:1255326286
Name:LAURICH, LARRY
Entity Type:Individual
Prefix:
First Name:LARRY
Middle Name:
Last Name:LAURICH
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 1:618 N UNIVERSITY DR
Mailing Address - Street 2:
Mailing Address - City:NACOGDOCHES
Mailing Address - State:TX
Mailing Address - Zip Code:75961-4617
Mailing Address - Country:US
Mailing Address - Phone:936-569-7460
Mailing Address - Fax:936-560-5840
Practice Address - Street 1:618 N UNIVERSITY DR
Practice Address - Street 2:
Practice Address - City:NACOGDOCHES
Practice Address - State:TX
Practice Address - Zip Code:75961-4617
Practice Address - Country:US
Practice Address - Phone:936-569-7460
Practice Address - Fax:936-560-5840
Is Sole Proprietor?:Yes
Enumeration Date:2005-09-15
Last Update Date:2011-10-21
Deactivation Date:2006-03-23
Deactivation Code:
Reactivation Date:2006-03-27
Provider Licenses
StateLicense IDTaxonomies
TX810213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX110223801Medicaid
TX159733801Medicaid
TXT14344Medicare UPIN
TX0424990002Medicare NSC
TX00SD38Medicare PIN