Provider Demographics
NPI:1578564498
Name:JONES, LARRY W (MD)
Entity Type:Individual
Prefix:
First Name:LARRY
Middle Name:W
Last Name:JONES
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 75
Mailing Address - Street 2:
Mailing Address - City:ROARING SPRING
Mailing Address - State:PA
Mailing Address - Zip Code:16673-0075
Mailing Address - Country:US
Mailing Address - Phone:814-224-4439
Mailing Address - Fax:814-224-5930
Practice Address - Street 1:99 NASON DR
Practice Address - Street 2:
Practice Address - City:ROARING SPRING
Practice Address - State:PA
Practice Address - Zip Code:16673-1203
Practice Address - Country:US
Practice Address - Phone:814-224-4439
Practice Address - Fax:814-224-5930
Is Sole Proprietor?:Yes
Enumeration Date:2005-08-02
Last Update Date:2014-04-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD009439E207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA1084266Medicaid
127915Medicare ID - Type Unspecified
PA1084266Medicaid