Provider Demographics
NPI:1255372900
Name:LEADBETTER, LARRY M (MD)
Entity type:Individual
Prefix:
First Name:LARRY
Middle Name:M
Last Name:LEADBETTER
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 1:705 PLEASANT AVE S
Mailing Address - Street 2:
Mailing Address - City:PARK RAPIDS
Mailing Address - State:MN
Mailing Address - Zip Code:56470-1440
Mailing Address - Country:US
Mailing Address - Phone:218-732-2800
Mailing Address - Fax:218-732-2857
Practice Address - Street 1:705 PLEASANT AVE S
Practice Address - Street 2:
Practice Address - City:PARK RAPIDS
Practice Address - State:MN
Practice Address - Zip Code:56470-1440
Practice Address - Country:US
Practice Address - Phone:218-732-2800
Practice Address - Fax:218-732-2857
Is Sole Proprietor?:No
Enumeration Date:2006-06-10
Last Update Date:2011-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN36604207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN0402550OtherMEDICA #
MN0402551OtherMEDICA #
MN110073027OtherRR MEDICARE #
MN167284OtherUCARE #
MN0403068OtherMEDICA #
MN2M786LEOtherMNBS #
MN899037OtherAMERICA'S PPO/ARAZ #
MN692765300Medicaid
MN11721OtherNDBS #
MN8F747LEOtherMNBS #
MNDA9041015687OtherPREFERRED ONE #
MN8F746LEOtherMNBS #
MNHP19540OtherHEALTHPARTNERS #
MNMN100005OtherLHS/BANNERHEALTH #
MN11721OtherNDBS #
MNHP19540OtherHEALTHPARTNERS #
MN119002263Medicare ID - Type UnspecifiedMN MEDICARE #
MN692765300Medicaid