Provider Demographics
NPI:1720476807
Name:TOLER, LARRY
Entity Type:Individual
Prefix:
First Name:LARRY
Middle Name:
Last Name:TOLER
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 1:1870 KING ARTHUR CIR
Mailing Address - Street 2:
Mailing Address - City:MAITLAND
Mailing Address - State:FL
Mailing Address - Zip Code:32751-5865
Mailing Address - Country:US
Mailing Address - Phone:407-766-4817
Mailing Address - Fax:407-629-5266
Practice Address - Street 1:1870 KING ARTHUR CIR
Practice Address - Street 2:
Practice Address - City:MAITLAND
Practice Address - State:FL
Practice Address - Zip Code:32751-5865
Practice Address - Country:US
Practice Address - Phone:407-766-4817
Practice Address - Fax:407-629-5266
Is Sole Proprietor?:Yes
Enumeration Date:2014-12-25
Last Update Date:2014-12-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLA266190171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLA266190Medicare PIN