Provider Demographics
NPI:1124244041
Name:FICKENSCHER, LARRY GEORGE (MD)
Entity type:Individual
Prefix:
First Name:LARRY
Middle Name:GEORGE
Last Name:FICKENSCHER
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 1:3945 TIMBERCREST RD
Mailing Address - Street 2:
Mailing Address - City:EUGENE
Mailing Address - State:OR
Mailing Address - Zip Code:97405-4974
Mailing Address - Country:US
Mailing Address - Phone:541-484-4976
Mailing Address - Fax:541-484-2587
Practice Address - Street 1:UNIVERSITY OF OREGON STUDENT HEALTH CENTER
Practice Address - Street 2:1590 EAST 13TH AVENUE
Practice Address - City:EUGENE
Practice Address - State:OR
Practice Address - Zip Code:97403-1232
Practice Address - Country:US
Practice Address - Phone:541-346-4447
Practice Address - Fax:541-346-2747
Is Sole Proprietor?:No
Enumeration Date:2007-04-18
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR113392080H0002X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2080H0002XAllopathic & Osteopathic PhysiciansPediatricsHospice and Palliative Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR007179OtherOMAP
ORA41352Medicare UPIN
OR037WCJLJAMedicare ID - Type Unspecified