Provider Demographics
NPI:1881767622
Name:HAM, LARRY (MD)
Entity type:Individual
Prefix:
First Name:LARRY
Middle Name:
Last Name:HAM
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 1:176 N VILLAGE AVE
Mailing Address - Street 2:SUITE 1C
Mailing Address - City:ROCKVILLE CENTRE
Mailing Address - State:NY
Mailing Address - Zip Code:11570-3800
Mailing Address - Country:US
Mailing Address - Phone:516-594-1068
Mailing Address - Fax:
Practice Address - Street 1:176 N VILLAGE AVE
Practice Address - Street 2:SUITE 1C
Practice Address - City:ROCKVILLE CENTRE
Practice Address - State:NY
Practice Address - Zip Code:11570-3800
Practice Address - Country:US
Practice Address - Phone:516-594-1068
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-17
Last Update Date:2007-11-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY213395207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02105200Medicaid
NY144C01Medicare ID - Type UnspecifiedMEDICARE NUMBER
NY02105200Medicaid