Provider Demographics
NPI:1629179171
Name:FARR, LARRY D (DO)
Entity type:Individual
Prefix:
First Name:LARRY
Middle Name:D
Last Name:FARR
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:PO BOX 67000
Mailing Address - Street 2:DEPT 272801
Mailing Address - City:DETROIT
Mailing Address - State:MI
Mailing Address - Zip Code:48267-2728
Mailing Address - Country:US
Mailing Address - Phone:517-787-8250
Mailing Address - Fax:517-787-1612
Practice Address - Street 1:3235 E MICHIGAN AVE
Practice Address - Street 2:
Practice Address - City:JACKSON
Practice Address - State:MI
Practice Address - Zip Code:49202-3971
Practice Address - Country:US
Practice Address - Phone:517-787-8250
Practice Address - Fax:517-787-1612
Is Sole Proprietor?:No
Enumeration Date:2006-09-26
Last Update Date:2011-12-30
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MI5101007126207QA0505X, 207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No207QA0505XAllopathic & Osteopathic PhysiciansFamily MedicineAdult Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MIE31543Medicare UPIN