Provider Demographics
NPI:1780680793
Name:DODD, LARRY A (MD)
Entity Type:Individual
Prefix:
First Name:LARRY
Middle Name:A
Last Name:DODD
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 6847
Mailing Address - Street 2:
Mailing Address - City:WHEELING
Mailing Address - State:WV
Mailing Address - Zip Code:26003-0666
Mailing Address - Country:US
Mailing Address - Phone:304-234-2061
Mailing Address - Fax:304-234-2070
Practice Address - Street 1:20 MEDICAL PARK
Practice Address - Street 2:SUITE 223
Practice Address - City:WHEELING
Practice Address - State:WV
Practice Address - Zip Code:26003-6390
Practice Address - Country:US
Practice Address - Phone:304-234-2061
Practice Address - Fax:304-234-2070
Is Sole Proprietor?:No
Enumeration Date:2005-06-23
Last Update Date:2007-10-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV09198207Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Y00000XAllopathic & Osteopathic PhysiciansOtolaryngology
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0419738Medicaid
WV1802957000Medicaid
B42514Medicare UPIN
WV1802957000Medicaid