Provider Demographics
NPI:1942310818
Name:ALLEN, LARRY D (MD)
Entity Type:Individual
Prefix:
First Name:LARRY
Middle Name:D
Last Name:ALLEN
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 158
Mailing Address - Street 2:
Mailing Address - City:SYRACUSE
Mailing Address - State:IN
Mailing Address - Zip Code:46567-0158
Mailing Address - Country:US
Mailing Address - Phone:574-457-5701
Mailing Address - Fax:574-457-5609
Practice Address - Street 1:1033 N INDIANA AVE
Practice Address - Street 2:
Practice Address - City:SYRACUSE
Practice Address - State:IN
Practice Address - Zip Code:46567-1017
Practice Address - Country:US
Practice Address - Phone:574-457-5701
Practice Address - Fax:574-457-5609
Is Sole Proprietor?:No
Enumeration Date:2006-08-30
Last Update Date:2023-04-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01042097207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN100428310Medicaid
IN184520009Medicare PIN
IN100428310Medicaid
IN100428310Medicaid