Provider Demographics
NPI:1558404202
Name:CLEVENGER, LARRY RUSSEL (MD)
Entity Type:Individual
Prefix:DR
First Name:LARRY
Middle Name:RUSSEL
Last Name:CLEVENGER
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 1:1515 EUBANK BLVD NE
Mailing Address - Street 2:
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87112-4112
Mailing Address - Country:US
Mailing Address - Phone:505-845-8037
Mailing Address - Fax:
Practice Address - Street 1:1515 EUBANK BLVD NE
Practice Address - Street 2:
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87112-4112
Practice Address - Country:US
Practice Address - Phone:505-845-8037
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-14
Last Update Date:2013-09-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM75-1262083X0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2083X0100XAllopathic & Osteopathic PhysiciansPreventive MedicineOccupational Medicine