Provider Demographics
NPI:1518058163
Name:EBBERT, LARRY P (MD)
Entity Type:Individual
Prefix:
First Name:LARRY
Middle Name:P
Last Name:EBBERT
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 1:6603 ELK CREEK RD
Mailing Address - Street 2:
Mailing Address - City:PIEDMONT
Mailing Address - State:SD
Mailing Address - Zip Code:57769-2032
Mailing Address - Country:US
Mailing Address - Phone:605-484-1176
Mailing Address - Fax:
Practice Address - Street 1:85 MAUI LANI PKWY
Practice Address - Street 2:
Practice Address - City:WAILUKU
Practice Address - State:HI
Practice Address - Zip Code:96793-2416
Practice Address - Country:US
Practice Address - Phone:808-442-5700
Practice Address - Fax:808-442-5652
Is Sole Proprietor?:No
Enumeration Date:2006-09-27
Last Update Date:2023-05-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SD2083207RH0000X
SD74117207RX0202X
HIMD-21014207RH0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RH0003XAllopathic & Osteopathic PhysiciansInternal MedicineHematology & Oncology
No207RH0000XAllopathic & Osteopathic PhysiciansInternal MedicineHematology
No207RX0202XAllopathic & Osteopathic PhysiciansInternal MedicineMedical Oncology
Provider Identifiers
StateIdentifier IDID TypeIssuer
SD0008428OtherWELLMARK
SD830007858OtherRR MEDICARE
SD2083OtherDAKOTACARE
SD6002482Medicaid
SD2083OtherDAKOTACARE