Provider Demographics
NPI:1487657664
Name:BURCH, LARRY (DO)
Entity Type:Individual
Prefix:
First Name:LARRY
Middle Name:
Last Name:BURCH
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 846098
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75284-6098
Mailing Address - Country:US
Mailing Address - Phone:903-324-6400
Mailing Address - Fax:
Practice Address - Street 1:313 W PARKER
Practice Address - Street 2:
Practice Address - City:ELKHART
Practice Address - State:TX
Practice Address - Zip Code:75839-7612
Practice Address - Country:US
Practice Address - Phone:903-764-5626
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-05-23
Last Update Date:2018-09-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXF3795207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX126138001Medicaid
TX81W718Medicare ID - Type Unspecified
TX126138001Medicaid