Provider Demographics
NPI:1437115821
Name:KILLOUGH, LARRY R (MD)
Entity Type:Individual
Prefix:
First Name:LARRY
Middle Name:R
Last Name:KILLOUGH
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:623 N 9TH STREET
Mailing Address - Street 2:PO BOX 497
Mailing Address - City:AUGUSTA
Mailing Address - State:AR
Mailing Address - Zip Code:72006
Mailing Address - Country:US
Mailing Address - Phone:870-347-3300
Mailing Address - Fax:870-347-3492
Practice Address - Street 1:606 WILBUR D MILLS NORTH
Practice Address - Street 2:
Practice Address - City:KENSETT
Practice Address - State:AR
Practice Address - Zip Code:72082
Practice Address - Country:US
Practice Address - Phone:501-742-5697
Practice Address - Fax:501-742-3031
Is Sole Proprietor?:No
Enumeration Date:2006-04-25
Last Update Date:2011-05-31
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
ARC2942207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR103621001Medicaid
AR10065798Medicare PIN
B90347Medicare UPIN
AR52880Medicare PIN
AR57297Medicare PIN