Healthcare Provider Details

I. General information

NPI: 1518058163
Provider Name (Legal Business Name): LARRY P EBBERT MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/27/2006
Last Update Date: 03/16/2025
Certification Date: 03/16/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

85 MAUI LANI PKWY
WAILUKU HI
96793-2416
US

IV. Provider business mailing address

6603 ELK CREEK RD
PIEDMONT SD
57769-2032
US

V. Phone/Fax

Practice location:
  • Phone: 808-442-5700
  • Fax: 808-442-5652
Mailing address:
  • Phone: 605-484-1176
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207RH0000X
TaxonomyHematology (Internal Medicine) Physician
License Number2083
License Number StateSD
# 2
Primary TaxonomyN
Taxonomy Code207RH0003X
TaxonomyHematology & Oncology Physician
License NumberMC-274
License Number StateGU
# 3
Primary TaxonomyN
Taxonomy Code207RX0202X
TaxonomyMedical Oncology Physician
License Number74117
License Number StateSD
# 4
Primary TaxonomyY
Taxonomy Code207RH0003X
TaxonomyHematology & Oncology Physician
License NumberMD-21014
License Number StateHI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: