Provider Demographics
NPI:1992754345
Name:FANE, LARRY RALPH (M D)
Entity type:Individual
Prefix:DR
First Name:LARRY
Middle Name:RALPH
Last Name:FANE
Suffix:
Gender:M
Credentials:M D
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:205 E UNIVERSITY AVE
Mailing Address - Street 2:SUITE 200
Mailing Address - City:GEORGETOWN
Mailing Address - State:TX
Mailing Address - Zip Code:78626-6814
Mailing Address - Country:US
Mailing Address - Phone:512-686-0207
Mailing Address - Fax:
Practice Address - Street 1:612 E UNIVERSITY AVE
Practice Address - Street 2:
Practice Address - City:GEORGETOWN
Practice Address - State:TX
Practice Address - Zip Code:78626-7034
Practice Address - Country:US
Practice Address - Phone:512-930-5437
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-05-10
Last Update Date:2011-03-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXD7566208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX1309775-01Medicaid
TX82K852Medicare ID - Type Unspecified
TX1309775-01Medicaid