Provider Demographics
NPI:1851486575
Name:WADSWORTH, LARKIN TYLER III (MD)
Entity Type:Individual
Prefix:DR
First Name:LARKIN
Middle Name:TYLER
Last Name:WADSWORTH
Suffix:III
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:8225 CLAYTON RD
Mailing Address - Street 2:
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63117-1107
Mailing Address - Country:US
Mailing Address - Phone:314-721-7325
Mailing Address - Fax:314-721-1157
Practice Address - Street 1:8225 CLAYTON RD
Practice Address - Street 2:
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63117-1107
Practice Address - Country:US
Practice Address - Phone:314-721-7325
Practice Address - Fax:314-721-1157
Is Sole Proprietor?:No
Enumeration Date:2006-10-04
Last Update Date:2012-08-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO103386207QS0010X
IL036118172207QS0010X, 207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207QS0010XAllopathic & Osteopathic PhysiciansFamily MedicineSports Medicine
No207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
000006158Medicare ID - Type Unspecified
E42305Medicare UPIN