Provider Demographics
NPI:1689749582
Name:WILSON, LARRY FLICK (MD)
Entity Type:Individual
Prefix:DR
First Name:LARRY
Middle Name:FLICK
Last Name:WILSON
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 1:180 ROCKBRIDGE PARKWAY
Mailing Address - Street 2:
Mailing Address - City:EXCELSIOR SPRINGS
Mailing Address - State:MO
Mailing Address - Zip Code:64024
Mailing Address - Country:US
Mailing Address - Phone:816-630-0771
Mailing Address - Fax:
Practice Address - Street 1:FAA, ACE-300
Practice Address - Street 2:901 LOCUST STREET, RM 350
Practice Address - City:KANSAS CITY
Practice Address - State:MO
Practice Address - Zip Code:64106
Practice Address - Country:US
Practice Address - Phone:816-329-3250
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-24
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE127352083A0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2083A0100XAllopathic & Osteopathic PhysiciansPreventive MedicineAerospace Medicine