Provider Demographics
NPI:1932157856
Name:ANDERSON, LARRY W (DO)
Entity type:Individual
Prefix:DR
First Name:LARRY
Middle Name:W
Last Name:ANDERSON
Suffix:
Gender:M
Credentials:DO
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Mailing Address - Street 1:81 NORTHSIDE DAWSON DR
Mailing Address - Street 2:STE 205
Mailing Address - City:DAWSONVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30534-7166
Mailing Address - Country:US
Mailing Address - Phone:706-265-1335
Mailing Address - Fax:706-265-2296
Practice Address - Street 1:81 NORTHSIDE DAWSON DR
Practice Address - Street 2:STE 205
Practice Address - City:DAWSONVILLE
Practice Address - State:GA
Practice Address - Zip Code:30534-7166
Practice Address - Country:US
Practice Address - Phone:706-265-1335
Practice Address - Fax:706-265-2296
Is Sole Proprietor?:No
Enumeration Date:2006-05-04
Last Update Date:2020-08-07
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
GA020648207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
GAP00419457OtherRAILROAD MEDICARE PTAN
GA003138628AMedicaid
GA08BCBCNOtherLEGACY
GA202I087443Medicare PIN
GA003138628AMedicaid