Provider Demographics
NPI:1639149172
Name:JONES, LARRY R (MD)
Entity Type:Individual
Prefix:MR
First Name:LARRY
Middle Name:R
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 1105
Mailing Address - Street 2:
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46206-1105
Mailing Address - Country:US
Mailing Address - Phone:618-252-8625
Mailing Address - Fax:618-252-2540
Practice Address - Street 1:117 E CLARK ST
Practice Address - Street 2:
Practice Address - City:HARRISBURG
Practice Address - State:IL
Practice Address - Zip Code:62946
Practice Address - Country:US
Practice Address - Phone:618-252-8625
Practice Address - Fax:618-252-2540
Is Sole Proprietor?:No
Enumeration Date:2006-01-26
Last Update Date:2014-01-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036055993207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036055993Medicaid
615040Medicare ID - Type Unspecified
D13920Medicare UPIN
IL036055993Medicaid