Provider Demographics
NPI:1861416455
Name:DE PEDRO, LARRY H (MD)
Entity type:Individual
Prefix:
First Name:LARRY
Middle Name:H
Last Name:DE PEDRO
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:HILARIO
Other - Middle Name:H
Other - Last Name:DE PEDRO
Other - Suffix:IV
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1120 N MELVIN ST
Mailing Address - Street 2:
Mailing Address - City:GIBSON CITY
Mailing Address - State:IL
Mailing Address - Zip Code:60936-1477
Mailing Address - Country:US
Mailing Address - Phone:217-283-5530
Mailing Address - Fax:
Practice Address - Street 1:705 S DIXIE HWY
Practice Address - Street 2:
Practice Address - City:HOOPESTON
Practice Address - State:IL
Practice Address - Zip Code:60942-1904
Practice Address - Country:US
Practice Address - Phone:217-283-5530
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-27
Last Update Date:2020-08-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036-116088207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036116088Medicaid