Provider Demographics
NPI:1700997160
Name:DANIELS, LARRY CLYDE (MD)
Entity Type:Individual
Prefix:DR
First Name:LARRY
Middle Name:CLYDE
Last Name:DANIELS
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 1:350 JORDAN STREET
Mailing Address - Street 2:
Mailing Address - City:SHREVEPORT
Mailing Address - State:LA
Mailing Address - Zip Code:71101
Mailing Address - Country:US
Mailing Address - Phone:318-779-2417
Mailing Address - Fax:318-742-8646
Practice Address - Street 1:350 JORDAN ST
Practice Address - Street 2:
Practice Address - City:SHREVEPORT
Practice Address - State:LA
Practice Address - Zip Code:71101-4847
Practice Address - Country:US
Practice Address - Phone:318-779-2417
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-31
Last Update Date:2019-11-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA06282R207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1352896Medicaid
LAB63071Medicare UPIN
LA51444CH52Medicare PIN
LA51444Medicare ID - Type Unspecified