Provider Demographics
NPI:1942213475
Name:TICE, LARRY D (MD)
Entity Type:Individual
Prefix:
First Name:LARRY
Middle Name:D
Last Name:TICE
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 1:551 KOKOPELLI BLVD UNIT I
Mailing Address - Street 2:
Mailing Address - City:FRUITA
Mailing Address - State:CO
Mailing Address - Zip Code:81521-6305
Mailing Address - Country:US
Mailing Address - Phone:970-858-2580
Mailing Address - Fax:970-858-3211
Practice Address - Street 1:551 KOKOPELLI BLVD
Practice Address - Street 2:SUITE I
Practice Address - City:FRUITA
Practice Address - State:CO
Practice Address - Zip Code:81521-6305
Practice Address - Country:US
Practice Address - Phone:970-858-2580
Practice Address - Fax:970-858-3211
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-14
Last Update Date:2014-04-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO18565207T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207T00000XAllopathic & Osteopathic PhysiciansNeurological Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO01185651Medicaid
COC806720Medicare PIN
COD23460Medicare UPIN
COCOA106278Medicare PIN