Provider Demographics
NPI:1255497186
Name:DEKLE, LARRY CARLTON (MD)
Entity Type:Individual
Prefix:
First Name:LARRY
Middle Name:CARLTON
Last Name:DEKLE
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 1:1120 WOLF CREEK RD
Mailing Address - Street 2:
Mailing Address - City:WALNUT COVE
Mailing Address - State:NC
Mailing Address - Zip Code:27052-5752
Mailing Address - Country:US
Mailing Address - Phone:336-994-4264
Mailing Address - Fax:
Practice Address - Street 1:405 NC 65
Practice Address - Street 2:
Practice Address - City:WENTWORTH
Practice Address - State:NC
Practice Address - Zip Code:27375-0355
Practice Address - Country:US
Practice Address - Phone:336-342-8316
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-12-28
Last Update Date:2014-02-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCNC213932084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC892827BMedicaid
D92695Medicare UPIN
NC212969CMedicare ID - Type Unspecified