Provider Demographics
NPI:1881630051
Name:OKERLUND, LARRY BURTON (MD)
Entity type:Individual
Prefix:
First Name:LARRY
Middle Name:BURTON
Last Name:OKERLUND
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 1:4300 MARKETPOINTE DR STE 100
Mailing Address - Street 2:
Mailing Address - City:BLOOMINGTON
Mailing Address - State:MN
Mailing Address - Zip Code:55435-5435
Mailing Address - Country:US
Mailing Address - Phone:952-835-9880
Mailing Address - Fax:
Practice Address - Street 1:4300 MARKETPOINTE DR STE 100
Practice Address - Street 2:
Practice Address - City:BLOOMINGTON
Practice Address - State:MN
Practice Address - Zip Code:55435-5435
Practice Address - Country:US
Practice Address - Phone:952-835-9880
Practice Address - Fax:952-857-1554
Is Sole Proprietor?:No
Enumeration Date:2006-06-22
Last Update Date:2024-11-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN26600207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MNN003453OtherCHAMPUS
MN5H099OKOtherBCBS
GA080075002OtherRAILROAD MEDICARE
MN557203700Medicaid
MN089004008Medicare ID - Type Unspecified
MND48859Medicare UPIN
GA080075002OtherRAILROAD MEDICARE