Provider Demographics
NPI:1477609741
Name:GANZ, LARRY SAMUEL (MD)
Entity Type:Individual
Prefix:DR
First Name:LARRY
Middle Name:SAMUEL
Last Name:GANZ
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:916 N WEBER ST
Mailing Address - Street 2:
Mailing Address - City:COLORADO SPRINGS
Mailing Address - State:CO
Mailing Address - Zip Code:80903-2921
Mailing Address - Country:US
Mailing Address - Phone:719-448-9466
Mailing Address - Fax:719-448-9467
Practice Address - Street 1:916 N WEBER ST
Practice Address - Street 2:
Practice Address - City:COLORADO SPRINGS
Practice Address - State:CO
Practice Address - Zip Code:80903-2921
Practice Address - Country:US
Practice Address - Phone:719-448-9466
Practice Address - Fax:719-448-9467
Is Sole Proprietor?:No
Enumeration Date:2007-01-26
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO307432080P0006X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2080P0006XAllopathic & Osteopathic PhysiciansPediatricsDevelopmental - Behavioral Pediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO01307438Medicaid