Healthcare Provider Details

I. General information

NPI: 1033177829
Provider Name (Legal Business Name): LARRY B THEAD M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/02/2006
Last Update Date: 02/19/2021
Certification Date: 02/19/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

95 SHELL RD
SARALAND AL
36571-2202
US

IV. Provider business mailing address

1700 SPRING HILL AVE STE 100
MOBILE AL
36604-1416
US

V. Phone/Fax

Practice location:
  • Phone: 251-675-4733
  • Fax:
Mailing address:
  • Phone: 251-435-1200
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number9264
License Number StateAL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: