Provider Demographics
NPI:1366639981
Name:ANTHONY M.D. P.C., LARRY WILSON
Entity Type:Individual
Prefix:DR
First Name:LARRY
Middle Name:WILSON
Last Name:ANTHONY M.D. P.C.
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 1:360 E EH CRUMP BLVD
Mailing Address - Street 2:
Mailing Address - City:MEMPHIS
Mailing Address - State:TN
Mailing Address - Zip Code:38126-5310
Mailing Address - Country:US
Mailing Address - Phone:901-261-2000
Mailing Address - Fax:901-946-9262
Practice Address - Street 1:360 E EH CRUMP BLVD
Practice Address - Street 2:
Practice Address - City:MEMPHIS
Practice Address - State:TN
Practice Address - Zip Code:38126-5310
Practice Address - Country:US
Practice Address - Phone:901-261-2000
Practice Address - Fax:901-946-9262
Is Sole Proprietor?:No
Enumeration Date:2007-09-27
Last Update Date:2017-04-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNMD0000026073207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TND39307Medicare UPIN
TN3373169Medicare PIN