Provider Demographics
NPI:1275507204
Name:LARRINAGA, JOHN A (MD)
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:A
Last Name:LARRINAGA
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 846098
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75284-6098
Mailing Address - Country:US
Mailing Address - Phone:903-324-6450
Mailing Address - Fax:
Practice Address - Street 1:520 DOUGLAS BLVD
Practice Address - Street 2:
Practice Address - City:TYLER
Practice Address - State:TX
Practice Address - Zip Code:75702-8307
Practice Address - Country:US
Practice Address - Phone:903-510-1175
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-02-15
Last Update Date:2014-10-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXL45162085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX152466203Medicaid
TX152466202Medicaid
TX152450601Medicaid
TX8CU211OtherBCBS MFH JV LOCATION
TX8B0526OtherBCBS
TX152466201Medicaid
TXTIN PLUS 005OtherTRICARE MFH JV LOCATION
TXTIN PLUS 113OtherTRICARE
TXP00945876Medicare PIN
TXTIN PLUS 005OtherTRICARE MFH JV LOCATION
TX300133620Medicare PIN
TX8B0526OtherBCBS
G52905Medicare UPIN
TX152466203Medicaid
TX152450601Medicaid