Provider Demographics
NPI:1699761981
Name:SUMNER, LARRY DEAN (MD)
Entity type:Individual
Prefix:DR
First Name:LARRY
Middle Name:DEAN
Last Name:SUMNER
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:204 WOODLAWN AVE
Mailing Address - Street 2:
Mailing Address - City:TAHLEQUAH
Mailing Address - State:OK
Mailing Address - Zip Code:74464-3318
Mailing Address - Country:US
Mailing Address - Phone:918-456-8000
Mailing Address - Fax:918-708-1609
Practice Address - Street 1:204 WOODLAWN AVE
Practice Address - Street 2:
Practice Address - City:TAHLEQUAH
Practice Address - State:OK
Practice Address - Zip Code:74464-3318
Practice Address - Country:US
Practice Address - Phone:918-456-8000
Practice Address - Fax:918-708-1609
Is Sole Proprietor?:Yes
Enumeration Date:2005-09-22
Last Update Date:2015-05-12
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
OK14708207QA0505X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207QA0505XAllopathic & Osteopathic PhysiciansFamily MedicineAdult Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OKB90241Medicare UPIN