Provider Demographics
NPI:1841305331
Name:HEATH, LARRY K (MD)
Entity type:Individual
Prefix:
First Name:LARRY
Middle Name:K
Last Name:HEATH
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
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Mailing Address - Street 1:136 LINDEN DR
Mailing Address - Street 2:SUITE 104
Mailing Address - City:WINCHESTER
Mailing Address - State:VA
Mailing Address - Zip Code:22601-6900
Mailing Address - Country:US
Mailing Address - Phone:540-678-3588
Mailing Address - Fax:540-678-9025
Practice Address - Street 1:493 BLACKWELL RD
Practice Address - Street 2:SUITE 101A
Practice Address - City:WARRENTON
Practice Address - State:VA
Practice Address - Zip Code:20186-2639
Practice Address - Country:US
Practice Address - Phone:540-316-4325
Practice Address - Fax:540-316-4331
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-21
Last Update Date:2011-08-02
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
VA0101243352207R00000X
WI32455207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI31770600Medicaid
WI040772200Medicare ID - Type Unspecified
A42672Medicare UPIN
WI31770600Medicaid