Provider Demographics
NPI:1366552218
Name:EASTERLING, LARRY E (MD)
Entity type:Individual
Prefix:
First Name:LARRY
Middle Name:E
Last Name:EASTERLING
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 99371
Mailing Address - Street 2:
Mailing Address - City:FORT WORTH
Mailing Address - State:TX
Mailing Address - Zip Code:76199-0371
Mailing Address - Country:US
Mailing Address - Phone:682-885-1855
Mailing Address - Fax:682-885-7347
Practice Address - Street 1:801 7TH AVE
Practice Address - Street 2:
Practice Address - City:FORT WORTH
Practice Address - State:TX
Practice Address - Zip Code:76104-2733
Practice Address - Country:US
Practice Address - Phone:682-885-4268
Practice Address - Fax:682-885-7956
Is Sole Proprietor?:No
Enumeration Date:2006-08-30
Last Update Date:2012-04-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXH96262080P0203X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2080P0203XAllopathic & Osteopathic PhysiciansPediatricsPediatric Critical Care Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX10032461OtherAMERIGROUP PIN
TX4301822OtherAETNA PIN
TX82Y892OtherBCBSTX IND PIN
TX1392703OtherUHC PIN
TX6414914OtherCIGNA PIN
TX00U87ZOtherBCBSTX GRP PIN
TX112097100OtherFIRSTCARE PIN
TX129718605Medicaid
TX129718606OtherCSHCN
TX124132OtherSUPERIOR PIN
1750369203OtherGRP NPI NUMBER
TX87143OtherPHCS PIN
TX1727198OtherFIRSTHEALTH PIN
8L20966Medicare PIN
TX1727198OtherFIRSTHEALTH PIN