Provider Demographics
NPI:1740238211
Name:AYCOCK, LARRY B (MD)
Entity Type:Individual
Prefix:DR
First Name:LARRY
Middle Name:B
Last Name:AYCOCK
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 1:103 ASBURY CIR
Mailing Address - Street 2:
Mailing Address - City:HATTIESBURG
Mailing Address - State:MS
Mailing Address - Zip Code:39402-1302
Mailing Address - Country:US
Mailing Address - Phone:601-268-5200
Mailing Address - Fax:601-268-5202
Practice Address - Street 1:103 ASBURY CIR
Practice Address - Street 2:
Practice Address - City:HATTIESBURG
Practice Address - State:MS
Practice Address - Zip Code:39402-1302
Practice Address - Country:US
Practice Address - Phone:601-268-5200
Practice Address - Fax:601-268-5202
Is Sole Proprietor?:No
Enumeration Date:2006-05-05
Last Update Date:2021-10-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS05242207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS00013655Medicaid
MS080263391Medicare PIN
MSB65982Medicare UPIN