Healthcare Provider Details

I. General information

NPI: 1861416455
Provider Name (Legal Business Name): LARRY H DE PEDRO MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

Provider Other Name: HILARIO H DE PEDRO IV

II. Dates (important events)

Enumeration Date: 07/27/2006
Last Update Date: 08/12/2020
Certification Date: 08/12/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

705 S DIXIE HWY
HOOPESTON IL
60942-1904
US

IV. Provider business mailing address

1120 N MELVIN ST
GIBSON CITY IL
60936-1477
US

V. Phone/Fax

Practice location:
  • Phone: 217-283-5530
  • Fax:
Mailing address:
  • Phone: 217-283-5530
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number036-116088
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: