Provider Demographics
NPI:1982629788
Name:REAVES, LARRY E (MD)
Entity Type:Individual
Prefix:
First Name:LARRY
Middle Name:E
Last Name:REAVES
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 733784
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75373-3784
Mailing Address - Country:US
Mailing Address - Phone:682-885-1860
Mailing Address - Fax:682-885-1396
Practice Address - Street 1:801 7TH AVE
Practice Address - Street 2:
Practice Address - City:FORT WORTH
Practice Address - State:TX
Practice Address - Zip Code:76104-2733
Practice Address - Country:US
Practice Address - Phone:682-885-6600
Practice Address - Fax:682-885-3938
Is Sole Proprietor?:No
Enumeration Date:2006-07-13
Last Update Date:2021-05-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXF19262086S0122X, 208200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208200000XAllopathic & Osteopathic PhysiciansPlastic Surgery
No2086S0122XAllopathic & Osteopathic PhysiciansSurgeryPlastic and Reconstructive Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
240008039OtherRAILROAD
TX132974011Medicaid
TX132974008Medicaid
TX132974010Medicaid
TX132974009Medicaid
240008037OtherRAILROAD