Provider Demographics
NPI:1518903160
Name:HRDLICKA, LARRY KYLE (DO)
Entity Type:Individual
Prefix:DR
First Name:LARRY
Middle Name:KYLE
Last Name:HRDLICKA
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:1220 N FLORENCE AVE
Mailing Address - Street 2:
Mailing Address - City:CLAREMORE
Mailing Address - State:OK
Mailing Address - Zip Code:74017-4381
Mailing Address - Country:US
Mailing Address - Phone:918-341-5311
Mailing Address - Fax:918-341-7338
Practice Address - Street 1:1220 N FLORENCE AVE
Practice Address - Street 2:
Practice Address - City:CLAREMORE
Practice Address - State:OK
Practice Address - Zip Code:74017-4381
Practice Address - Country:US
Practice Address - Phone:918-341-5311
Practice Address - Fax:918-341-7338
Is Sole Proprietor?:No
Enumeration Date:2006-06-21
Last Update Date:2016-12-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK8161208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK100118750AMedicaid
OK400522108Medicare ID - Type UnspecifiedMEDICARE
OK100118750AMedicaid