Provider Demographics
NPI:1407874399
Name:CROMWELL, LARRY GENE (MD)
Entity Type:Individual
Prefix:DR
First Name:LARRY
Middle Name:GENE
Last Name:CROMWELL
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
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Other - Credentials:
Mailing Address - Street 1:807 S PONDEROSA ST
Mailing Address - Street 2:
Mailing Address - City:PAYSON
Mailing Address - State:AZ
Mailing Address - Zip Code:85541-5542
Mailing Address - Country:US
Mailing Address - Phone:928-472-1357
Mailing Address - Fax:928-472-1290
Practice Address - Street 1:807 S PONDEROSA ST
Practice Address - Street 2:
Practice Address - City:PAYSON
Practice Address - State:AZ
Practice Address - Zip Code:85541-5542
Practice Address - Country:US
Practice Address - Phone:928-472-1357
Practice Address - Fax:928-472-1290
Is Sole Proprietor?:No
Enumeration Date:2006-07-18
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ270302085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
D92345Medicare UPIN