Provider Demographics
NPI:1851333447
Name:WATERBURY, LARRY (MD)
Entity Type:Individual
Prefix:
First Name:LARRY
Middle Name:
Last Name:WATERBURY
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 64474
Mailing Address - Street 2:
Mailing Address - City:BALTIMORE
Mailing Address - State:MD
Mailing Address - Zip Code:21264-4474
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:4940 EASTERN AVE
Practice Address - Street 2:
Practice Address - City:BALTIMORE
Practice Address - State:MD
Practice Address - Zip Code:21224-2735
Practice Address - Country:US
Practice Address - Phone:410-550-0519
Practice Address - Fax:
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-06-11
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDD09559207RH0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RH0003XAllopathic & Osteopathic PhysiciansInternal MedicineHematology & Oncology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MDKR52B651Medicare ID - Type Unspecified
MDB69837Medicare UPIN