Provider Demographics
NPI:1790817013
Name:WILCKEN, LARRY T (MD)
Entity Type:Individual
Prefix:DR
First Name:LARRY
Middle Name:T
Last Name:WILCKEN
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 1:3618 DRY FORK CANYON RD
Mailing Address - Street 2:
Mailing Address - City:VERNAL
Mailing Address - State:UT
Mailing Address - Zip Code:84078-9404
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:151 W 200 N
Practice Address - Street 2:
Practice Address - City:VERNAL
Practice Address - State:UT
Practice Address - Zip Code:84078-1907
Practice Address - Country:US
Practice Address - Phone:435-789-3342
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-03-12
Last Update Date:2010-03-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT158064-1205207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT05135Medicaid
NMH1232Medicaid
UTHSZ230Medicare PIN
UTHSZ216Medicare PIN
UT000012408Medicare ID - Type Unspecified151 W 200 N, VERNAL
UT05135Medicaid
NM320057Medicare Oscar/Certification
NMH52178Medicare PIN