Provider Demographics
NPI:1366439838
Name:UNDERWOOD, LARRY D (MD)
Entity Type:Individual
Prefix:
First Name:LARRY
Middle Name:D
Last Name:UNDERWOOD
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 1:7920 W 44TH AVE
Mailing Address - Street 2:
Mailing Address - City:WHEAT RIDGE
Mailing Address - State:CO
Mailing Address - Zip Code:80033-4506
Mailing Address - Country:US
Mailing Address - Phone:303-424-3206
Mailing Address - Fax:303-940-1099
Practice Address - Street 1:7920 W 44TH AVE
Practice Address - Street 2:
Practice Address - City:WHEAT RIDGE
Practice Address - State:CO
Practice Address - Zip Code:80033-4506
Practice Address - Country:US
Practice Address - Phone:303-424-3206
Practice Address - Fax:303-940-1099
Is Sole Proprietor?:Yes
Enumeration Date:2005-09-30
Last Update Date:2009-10-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO20049207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
Provider Identifiers
StateIdentifier IDID TypeIssuer
COD23705Medicare UPIN
CACD6118Medicare ID - Type UnspecifiedPROVIDER