Provider Demographics
NPI:1710996996
Name:WALLER, LARRY HENLE (MD)
Entity Type:Individual
Prefix:
First Name:LARRY
Middle Name:HENLE
Last Name:WALLER
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 1:500 S UNIVERSITY AVE
Mailing Address - Street 2:SUITE 316
Mailing Address - City:LITTLE ROCK
Mailing Address - State:AR
Mailing Address - Zip Code:72205-5302
Mailing Address - Country:US
Mailing Address - Phone:501-603-9600
Mailing Address - Fax:501-603-0042
Practice Address - Street 1:500 S UNIVERSITY AVE
Practice Address - Street 2:SUITE 316
Practice Address - City:LITTLE ROCK
Practice Address - State:AR
Practice Address - Zip Code:72205-5302
Practice Address - Country:US
Practice Address - Phone:501-603-9600
Practice Address - Fax:501-603-0042
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-05
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARE0253207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
04828OtherHEALTHSOURCE
16047000000OtherQUALCHOICE
7420056OtherUNITED HEALTHCARE
AR125849001Medicaid
71082800072205AOOtherTRICARE WPS
AR137315002Medicaid
71082800072205AOOtherTRICARE WPS
ARF89190Medicare UPIN