Provider Demographics
NPI:1295564847
Name:GERKEN, LARRY DOUGLAS
Entity type:Individual
Prefix:MR
First Name:LARRY
Middle Name:DOUGLAS
Last Name:GERKEN
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1316 E JACKSON AVE N
Mailing Address - Street 2:
Mailing Address - City:SAPULPA
Mailing Address - State:OK
Mailing Address - Zip Code:74066-3752
Mailing Address - Country:US
Mailing Address - Phone:918-724-1963
Mailing Address - Fax:
Practice Address - Street 1:1316 E JACKSON AVE N
Practice Address - Street 2:
Practice Address - City:SAPULPA
Practice Address - State:OK
Practice Address - Zip Code:74066-3752
Practice Address - Country:US
Practice Address - Phone:918-724-1963
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-07-31
Last Update Date:2024-07-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes175T00000XOther Service ProvidersPeer Specialist