Provider Demographics
NPI:1629009931
Name:MOBLY, LARRY G (DO)
Entity Type:Individual
Prefix:
First Name:LARRY
Middle Name:G
Last Name:MOBLY
Suffix:
Gender:M
Credentials:DO
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 269064
Mailing Address - Street 2:
Mailing Address - City:OKLAHOMA CITY
Mailing Address - State:OK
Mailing Address - Zip Code:73126-9064
Mailing Address - Country:US
Mailing Address - Phone:405-390-1800
Mailing Address - Fax:405-390-3846
Practice Address - Street 1:15679 NE 23RD ST
Practice Address - Street 2:
Practice Address - City:CHOCTAW
Practice Address - State:OK
Practice Address - Zip Code:73020-8592
Practice Address - Country:US
Practice Address - Phone:405-390-1800
Practice Address - Fax:405-390-3846
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-05
Last Update Date:2010-09-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK2025207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK100100430BMedicaid
OK249631018Medicare PIN
OK100100430BMedicaid