Provider Demographics
NPI:1588788749
Name:OLNEY, LARRY A (MD)
Entity type:Individual
Prefix:
First Name:LARRY
Middle Name:A
Last Name:OLNEY
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 1:11 SPARROW NEST POINT
Mailing Address - Street 2:
Mailing Address - City:SAINT HELENA ISLAND
Mailing Address - State:SC
Mailing Address - Zip Code:29920
Mailing Address - Country:US
Mailing Address - Phone:843-838-9953
Mailing Address - Fax:
Practice Address - Street 1:11 SPARROW NEST POINT
Practice Address - Street 2:
Practice Address - City:SAINT HELENA ISLAND
Practice Address - State:SC
Practice Address - Zip Code:29920
Practice Address - Country:US
Practice Address - Phone:843-838-9953
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-16
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA41097174400000X
NMMD2005-0702174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MAD88134Medicare UPIN