Provider Demographics
NPI:1821064098
Name:LEWELLYN, LARRY L (DO)
Entity Type:Individual
Prefix:DR
First Name:LARRY
Middle Name:L
Last Name:LEWELLYN
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4007 JAMES CASEY ST
Mailing Address - Street 2:SUITE A150
Mailing Address - City:AUSTIN
Mailing Address - State:TX
Mailing Address - Zip Code:78745-3369
Mailing Address - Country:US
Mailing Address - Phone:512-447-0707
Mailing Address - Fax:
Practice Address - Street 1:4007 JAMES CASEY ST
Practice Address - Street 2:SUITE A150
Practice Address - City:AUSTIN
Practice Address - State:TX
Practice Address - Zip Code:78745-3369
Practice Address - Country:US
Practice Address - Phone:512-447-0707
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-02-27
Last Update Date:2011-09-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXG4336208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX127141301Medicaid
TXA67332Medicare UPIN