Provider Demographics
NPI:1598714875
Name:SELLERS, LARRY W (MD)
Entity Type:Individual
Prefix:
First Name:LARRY
Middle Name:W
Last Name:SELLERS
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 328
Mailing Address - Street 2:
Mailing Address - City:SIOUX CITY
Mailing Address - State:IA
Mailing Address - Zip Code:51102-0328
Mailing Address - Country:US
Mailing Address - Phone:712-279-5830
Mailing Address - Fax:712-279-5883
Practice Address - Street 1:801 5TH ST
Practice Address - Street 2:
Practice Address - City:SIOUX CITY
Practice Address - State:IA
Practice Address - Zip Code:51101-1394
Practice Address - Country:US
Practice Address - Phone:712-279-2010
Practice Address - Fax:712-279-5883
Is Sole Proprietor?:No
Enumeration Date:2006-05-06
Last Update Date:2007-10-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA26971207R00000X, 208M00000X
NE21998207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208M00000XAllopathic & Osteopathic PhysiciansHospitalist
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NE3053389Medicaid
IA421283849-46Medicaid
IA4053389Medicaid
NE35828OtherBCBSNE - SOUTH SIOUX
NE421283849-12Medicaid
IA33531OtherWELLMARK BCBS - M.M. PHYS
IA421283849-46Medicaid
IA4053389Medicaid
A25943Medicare UPIN