Basic Information
| Provider Information | |||||||||
| NPI: | 1184674210 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | LARRY WAMPLER DO PC | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 932 | ||||||||
| Address2: | |||||||||
| City: | CORVALLIS | ||||||||
| State: | OR | ||||||||
| PostalCode: | 973390932 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5417585047 | ||||||||
| FaxNumber: | 5417583713 | ||||||||
| Practice Location | |||||||||
| Address1: | 930 SW ABBEY ST | ||||||||
| Address2: | |||||||||
| City: | NEWPORT | ||||||||
| State: | OR | ||||||||
| PostalCode: | 973654820 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5412652244 | ||||||||
| FaxNumber: | 5415742858 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/11/2006 | ||||||||
| LastUpdateDate: | 05/07/2008 | ||||||||
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| AuthorizedOfficialLastName: | WAMPLER | ||||||||
| AuthorizedOfficialFirstName: | LARRY | ||||||||
| AuthorizedOfficialMiddleName: | R | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 5417585047 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | DO | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2085R0202X | 11879 | OR | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology |
ID Information
| ID | Type | State | Issuer | Description | 230987 | 05 | OR | MEDICAID |