Provider Demographics
NPI:1396768289
Name:LARGAESPADA, MANUEL (MD)
Entity type:Individual
Prefix:
First Name:MANUEL
Middle Name:
Last Name:LARGAESPADA
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 1:612 INDIAN LAKE DR
Mailing Address - Street 2:
Mailing Address - City:WRIGHT CITY
Mailing Address - State:MO
Mailing Address - Zip Code:63390-2953
Mailing Address - Country:US
Mailing Address - Phone:636-745-8371
Mailing Address - Fax:
Practice Address - Street 1:612 INDIAN LAKE DR
Practice Address - Street 2:
Practice Address - City:WRIGHT CITY
Practice Address - State:MO
Practice Address - Zip Code:63390-2953
Practice Address - Country:US
Practice Address - Phone:636-745-8371
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-25
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO105210207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MOE12225Medicare UPIN