Provider Demographics
NPI:1720096621
Name:HENDRICKS, LARRY D (DO)
Entity type:Individual
Prefix:DR
First Name:LARRY
Middle Name:D
Last Name:HENDRICKS
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8365 CIRCLEWOOD DRIVE N.
Mailing Address - Street 2:
Mailing Address - City:SAGINAW
Mailing Address - State:MI
Mailing Address - Zip Code:48609
Mailing Address - Country:US
Mailing Address - Phone:989-245-8031
Mailing Address - Fax:
Practice Address - Street 1:8365 CIRCLEWOOD DRIVE N.
Practice Address - Street 2:
Practice Address - City:SAGINAW
Practice Address - State:MI
Practice Address - Zip Code:48609
Practice Address - Country:US
Practice Address - Phone:989-245-8031
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-04
Last Update Date:2018-04-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI005960207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI1956592Medicaid
MI5731824Medicare ID - Type Unspecified
MI1956592Medicaid