Provider Demographics
NPI:1154397255
Name:BUMGUARDNER, LARRY THOMAS (DO)
Entity type:Individual
Prefix:DR
First Name:LARRY
Middle Name:THOMAS
Last Name:BUMGUARDNER
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
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Other - Credentials:
Mailing Address - Street 1:9505 WEST CENTRAL STE 104
Mailing Address - Street 2:
Mailing Address - City:WICHITA
Mailing Address - State:KS
Mailing Address - Zip Code:67212-3801
Mailing Address - Country:US
Mailing Address - Phone:316-312-0002
Mailing Address - Fax:316-440-3200
Practice Address - Street 1:9505 WEST CENTRAL STE 104
Practice Address - Street 2:
Practice Address - City:WICHITA
Practice Address - State:KS
Practice Address - Zip Code:67212-3801
Practice Address - Country:US
Practice Address - Phone:316-312-0002
Practice Address - Fax:316-854-5644
Is Sole Proprietor?:No
Enumeration Date:2006-02-27
Last Update Date:2016-01-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS0519728207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
KST77431Medicare UPIN