Basic Information
Provider Information
NPI: 1144267766
EntityType: 1
ReplacementNPI:  
OrganizationName:  
LastName: ANDERSON
FirstName: LARRY
MiddleName: D
NamePrefix: DR.
NameSuffix: JR.
Credential: M.D. , PHD
OtherOrganizationName:  
OtherOrganizationType:  
OtherLastName:  
OtherFirstName:  
OtherMiddleName:  
OtherNamePrefix:  
OtherNameSuffix:  
OtherCredential:  
OtherLastNameType:  
Mailing Information
Address1: PO BOX 845347
Address2:  
City: DALLAS
State: TX
PostalCode: 752847208
CountryCode: US
TelephoneNumber: 2146454673
FaxNumber:  
Practice Location
Address1: 2201 INWOOD RD
Address2:  
City: DALLAS
State: TX
PostalCode: 75235
CountryCode: US
TelephoneNumber: 2146454673
FaxNumber:  
Other Information
ProviderEnumerationDate: 06/01/2006
LastUpdateDate: 05/22/2019
NPIDeactivationReasonCode:  
NPIDeactivationDate:  
NPIReactivationDate:  
ProviderGenderCode: M
AuthorizedOfficialLastName:  
AuthorizedOfficialFirstName:  
AuthorizedOfficialMiddleName:  
AuthorizedOfficialTitleorPosition:  
AuthorizedOfficialTelephone:  
IsSoleProprietor: N
IsOrganizationSubpart:  
ParentOrganizationLBN:  
AuthorizedOfficialNamePrefix:  
AuthorizedOfficialNameSuffix:  
AuthorizedOfficialCredential:  
NPICertificationDate:  

Taxonomy Information
TaxonomyLicenseStateSwitchTaxonomyGroupTaxonomyTypeTaxonomyClassSubSpecialty
207RX0202XN0607TXY Allopathic & Osteopathic PhysiciansInternal MedicineMedical Oncology

ID Information
IDTypeStateIssuerDescription
845503205WA MEDICAID


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