Provider Demographics
NPI:1508824608
Name:WILF, LARRY H (MD)
Entity Type:Individual
Prefix:
First Name:LARRY
Middle Name:H
Last Name:WILF
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:PO BOX 102222
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30368-2222
Mailing Address - Country:US
Mailing Address - Phone:239-274-8200
Mailing Address - Fax:
Practice Address - Street 1:693 PONTE VEDRA BLVD UNIT A201
Practice Address - Street 2:
Practice Address - City:PONTE VEDRA BEACH
Practice Address - State:FL
Practice Address - Zip Code:32082-2989
Practice Address - Country:US
Practice Address - Phone:904-200-2409
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-05-01
Last Update Date:2022-09-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME50946174400000X, 2085R0202X, 207U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207U00000XAllopathic & Osteopathic PhysiciansNuclear Medicine
No174400000XOther Service ProvidersSpecialist
No2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL1119092OtherWELLCARE
FLP01451893OtherRR MEDICARE
FL006250600Medicaid
FL1226050OtherCIGNA
FL258093400Medicaid
FL03743OtherBCBS
FL5018006OtherAETNA
FLP01596525OtherRR MEDICARE
FLP00714011OtherRR MEDICARE
FL301208OtherAVMED
FLP00190196OtherMEDICARE RAILROAD
FLP00714011OtherRR MEDICARE
FL301208OtherAVMED
FL03743FMedicare PIN
FL1119092OtherWELLCARE
FLIB415YMedicare PIN
FL03743LMedicare PIN
FL03743JMedicare PIN
FL03743TMedicare PIN
FL5018006OtherAETNA
FL1226050OtherCIGNA
FLD20839Medicare UPIN
FL006250600Medicaid
FLIB415XMedicare PIN
FL03743GMedicare PIN
FL03743SMedicare PIN
FLIB415ZMedicare PIN
FL03743KMedicare PIN
FL258093400Medicaid