Provider Demographics
NPI:1407011208
Name:DAUGHERTY, LARRY CALVIN (MD)
Entity Type:Individual
Prefix:DR
First Name:LARRY
Middle Name:CALVIN
Last Name:DAUGHERTY
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 1:188 W NORTHERN LIGHTS BLVD STE 800
Mailing Address - Street 2:
Mailing Address - City:ANCHORAGE
Mailing Address - State:AK
Mailing Address - Zip Code:99503-3984
Mailing Address - Country:US
Mailing Address - Phone:907-276-2803
Mailing Address - Fax:
Practice Address - Street 1:188 W NORTHERN LIGHTS BLVD STE 100
Practice Address - Street 2:
Practice Address - City:ANCHORAGE
Practice Address - State:AK
Practice Address - Zip Code:99503-3902
Practice Address - Country:US
Practice Address - Phone:907-276-2803
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-07-22
Last Update Date:2014-09-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMT1932472085R0001X
FLME1125292085R0001X
AK83302085R0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0001XAllopathic & Osteopathic PhysiciansRadiologyRadiation Oncology
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL006593600Medicaid
FL006593600Medicaid