Provider Demographics
NPI:1306892757
Name:VANDERWOUDE, LARRY B (MD)
Entity type:Individual
Prefix:
First Name:LARRY
Middle Name:B
Last Name:VANDERWOUDE
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 1:2701 S KIWANIS AVE
Mailing Address - Street 2:
Mailing Address - City:SIOUX FALLS
Mailing Address - State:SD
Mailing Address - Zip Code:57105-4252
Mailing Address - Country:US
Mailing Address - Phone:605-328-9100
Mailing Address - Fax:605-328-9101
Practice Address - Street 1:2701 S KIWANIS AVE
Practice Address - Street 2:
Practice Address - City:SIOUX FALLS
Practice Address - State:SD
Practice Address - Zip Code:57105-4252
Practice Address - Country:US
Practice Address - Phone:605-328-9100
Practice Address - Fax:605-328-9101
Is Sole Proprietor?:No
Enumeration Date:2006-05-26
Last Update Date:2008-05-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SD2500207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
D25660Medicare UPIN
SD080193571Medicare PIN
SDS41033Medicare PIN
SD080193539Medicare PIN