Provider Demographics
NPI:1356344394
Name:CRADDOCK, LARRY W (MD)
Entity type:Individual
Prefix:
First Name:LARRY
Middle Name:W
Last Name:CRADDOCK
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 60447
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28260-0447
Mailing Address - Country:US
Mailing Address - Phone:704-321-1077
Mailing Address - Fax:704-321-1086
Practice Address - Street 1:1450 MATTHEWS TOWNSHIP PKWY
Practice Address - Street 2:SUITE 300
Practice Address - City:MATTHEWS
Practice Address - State:NC
Practice Address - Zip Code:28105-2387
Practice Address - Country:US
Practice Address - Phone:704-321-1077
Practice Address - Fax:704-321-1086
Is Sole Proprietor?:No
Enumeration Date:2005-05-23
Last Update Date:2015-03-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC18860207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC89011V2Medicaid
NC8925099Medicaid
NC205619FMedicare PIN
NC2308634GMedicare PIN