Provider Demographics
NPI:1134197643
Name:RICHARD, LARRY WAYNE (MD)
Entity type:Individual
Prefix:DR
First Name:LARRY
Middle Name:WAYNE
Last Name:RICHARD
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 1:302 NE 14TH ST
Mailing Address - Street 2:
Mailing Address - City:LEON
Mailing Address - State:IA
Mailing Address - Zip Code:50144-1206
Mailing Address - Country:US
Mailing Address - Phone:641-446-2383
Mailing Address - Fax:641-446-2382
Practice Address - Street 1:302 NE 14TH ST
Practice Address - Street 2:
Practice Address - City:LEON
Practice Address - State:IA
Practice Address - Zip Code:50144-1206
Practice Address - Country:US
Practice Address - Phone:641-446-2383
Practice Address - Fax:641-446-2382
Is Sole Proprietor?:No
Enumeration Date:2006-03-09
Last Update Date:2011-05-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA20202207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA3209254Medicaid
IAA02307Medicare UPIN