Provider Demographics
NPI:1609996982
Name:CRUEL, LARRY K (DPM)
Entity Type:Individual
Prefix:DR
First Name:LARRY
Middle Name:K
Last Name:CRUEL
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4510 OFFICE PARK DR
Mailing Address - Street 2:
Mailing Address - City:JACKSON
Mailing Address - State:MS
Mailing Address - Zip Code:39206-6016
Mailing Address - Country:US
Mailing Address - Phone:601-981-3001
Mailing Address - Fax:601-981-8999
Practice Address - Street 1:4510 OFFICE PARK DR
Practice Address - Street 2:
Practice Address - City:JACKSON
Practice Address - State:MS
Practice Address - Zip Code:39206-6016
Practice Address - Country:US
Practice Address - Phone:601-981-3001
Practice Address - Fax:601-981-8999
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-30
Last Update Date:2008-06-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS80152213EP1101X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213EP1101XPodiatric Medicine & Surgery Service ProvidersPodiatristPrimary Podiatric Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS00120141Medicaid
MS480000115Medicare ID - Type Unspecified