Provider Demographics
NPI:1386615490
Name:LOVALL, LARRY DWAYNE (MD)
Entity type:Individual
Prefix:MR
First Name:LARRY
Middle Name:DWAYNE
Last Name:LOVALL
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
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Other - Credentials:
Mailing Address - Street 1:208 MEADOW DR
Mailing Address - Street 2:
Mailing Address - City:DANVILLE
Mailing Address - State:IN
Mailing Address - Zip Code:46122-1416
Mailing Address - Country:US
Mailing Address - Phone:317-718-5523
Mailing Address - Fax:317-718-5576
Practice Address - Street 1:208 MEADOW DR
Practice Address - Street 2:
Practice Address - City:DANVILLE
Practice Address - State:IN
Practice Address - Zip Code:46122-1416
Practice Address - Country:US
Practice Address - Phone:317-718-5523
Practice Address - Fax:317-718-5576
Is Sole Proprietor?:Yes
Enumeration Date:2006-01-27
Last Update Date:2012-04-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01025398207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN100133310AMedicaid
IN100133310AMedicaid
D94782Medicare UPIN