Provider Demographics
NPI:1861474454
Name:DAVIS, LARRY R (MD)
Entity Type:Individual
Prefix:DR
First Name:LARRY
Middle Name:R
Last Name:DAVIS
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 1:2051 190TH STREET
Mailing Address - Street 2:
Mailing Address - City:FORT DODGE
Mailing Address - State:IA
Mailing Address - Zip Code:50501
Mailing Address - Country:US
Mailing Address - Phone:515-573-8487
Mailing Address - Fax:
Practice Address - Street 1:2051 190TH STREET
Practice Address - Street 2:
Practice Address - City:FORT DODGE
Practice Address - State:IA
Practice Address - Zip Code:50501
Practice Address - Country:US
Practice Address - Phone:515-573-8487
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2005-11-18
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA20999207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
IAIA0109OtherJOHN DEERE HEALTH
IA2146944Medicaid
IA43844OtherWELLMARK BCBS OF IA
A014OtherTRIWEST
A01297Medicare UPIN
IA2146944Medicaid