Provider Demographics
NPI:1316965221
Name:MEDDERS, LARRY L (MD)
Entity type:Individual
Prefix:DR
First Name:LARRY
Middle Name:L
Last Name:MEDDERS
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 1:2319 PRINCE AVE
Mailing Address - Street 2:
Mailing Address - City:ATHENS
Mailing Address - State:GA
Mailing Address - Zip Code:30606-6030
Mailing Address - Country:US
Mailing Address - Phone:706-354-1625
Mailing Address - Fax:706-543-4155
Practice Address - Street 1:2319 PRINCE AVE
Practice Address - Street 2:
Practice Address - City:ATHENS
Practice Address - State:GA
Practice Address - Zip Code:30606-6030
Practice Address - Country:US
Practice Address - Phone:706-354-1625
Practice Address - Fax:706-543-4155
Is Sole Proprietor?:No
Enumeration Date:2006-07-18
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA019078174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
GAD30218Medicare UPIN