Provider Demographics
NPI:1285600668
Name:DAVIS, LARRY J (MD)
Entity type:Individual
Prefix:
First Name:LARRY
Middle Name:J
Last Name:DAVIS
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:PO BOX 674047
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75267
Mailing Address - Country:US
Mailing Address - Phone:254-582-7481
Mailing Address - Fax:254-582-2199
Practice Address - Street 1:6901 MEDICAL PARKWAY
Practice Address - Street 2:
Practice Address - City:WACO
Practice Address - State:TX
Practice Address - Zip Code:76712
Practice Address - Country:US
Practice Address - Phone:254-582-7481
Practice Address - Fax:254-582-2199
Is Sole Proprietor?:No
Enumeration Date:2006-02-27
Last Update Date:2008-05-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXC15087173000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes173000000XOther Service ProvidersLegal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX8X5373OtherBLUE CROSS BLUE SHIELD
TX102739304Medicaid
TX102739301Medicaid
TX823492Medicare ID - Type Unspecified
TX102739301Medicaid
TXC15087Medicare UPIN
TX102739304Medicaid