Provider Demographics
NPI:1972701837
Name:WILLIAMSON, LARRY DEAN (MD)
Entity Type:Individual
Prefix:DR
First Name:LARRY
Middle Name:DEAN
Last Name:WILLIAMSON
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 1:330 S CASINO CENTER BLVD
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89101-6102
Mailing Address - Country:US
Mailing Address - Phone:702-671-5637
Mailing Address - Fax:702-366-0576
Practice Address - Street 1:330 S CASINO CENTER BLVD
Practice Address - Street 2:
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89101-6102
Practice Address - Country:US
Practice Address - Phone:702-671-5637
Practice Address - Fax:702-366-0576
Is Sole Proprietor?:Yes
Enumeration Date:2007-07-03
Last Update Date:2016-06-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV21286207Q00000X
NV8304207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV3910001135Medicaid
NV1972701837Medicaid
NV1972701837Medicaid