Provider Demographics
NPI:1760463798
Name:ANDERSON, LARRY ROGER (MD)
Entity Type:Individual
Prefix:
First Name:LARRY
Middle Name:ROGER
Last Name:ANDERSON
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 1:507 E 16TH ST
Mailing Address - Street 2:STE 1
Mailing Address - City:WELLINGTON
Mailing Address - State:KS
Mailing Address - Zip Code:67152-2828
Mailing Address - Country:US
Mailing Address - Phone:620-326-3301
Mailing Address - Fax:620-326-7086
Practice Address - Street 1:507 E 16TH ST
Practice Address - Street 2:STE 1
Practice Address - City:WELLINGTON
Practice Address - State:KS
Practice Address - Zip Code:67152-2828
Practice Address - Country:US
Practice Address - Phone:620-326-3301
Practice Address - Fax:620-326-7086
Is Sole Proprietor?:No
Enumeration Date:2005-11-08
Last Update Date:2020-05-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS15917207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
KS080048663OtherRR MEDICARE
KS100083720AMedicaid
CS5682OtherGROUP RAILROAD
CS5682OtherGROUP RAILROAD
KSB68323Medicare UPIN