Provider Demographics
NPI:1811965791
Name:FELICIANO, LARRY REYNOLDS (MD)
Entity type:Individual
Prefix:DR
First Name:LARRY
Middle Name:REYNOLDS
Last Name:FELICIANO
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:7601 HOSPITAL DRIVE # 209
Mailing Address - Street 2:
Mailing Address - City:SACRAMENTO
Mailing Address - State:CA
Mailing Address - Zip Code:95823-5408
Mailing Address - Country:US
Mailing Address - Phone:916-689-1966
Mailing Address - Fax:916-689-1238
Practice Address - Street 1:7601 HOSPITAL DR
Practice Address - Street 2:
Practice Address - City:SACRAMENTO
Practice Address - State:CA
Practice Address - Zip Code:95823-5408
Practice Address - Country:US
Practice Address - Phone:916-689-1966
Practice Address - Fax:916-689-1238
Is Sole Proprietor?:No
Enumeration Date:2006-03-08
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA51153207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CALAB12158FMedicaid
CALAB12158FMedicaid
CA00A511531Medicare ID - Type Unspecified