Healthcare Provider Details

I. General information

NPI: 1760463798
Provider Name (Legal Business Name): LARRY ROGER ANDERSON MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/08/2005
Last Update Date: 05/08/2020
Certification Date: 05/08/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

507 E 16TH ST STE 1
WELLINGTON KS
67152-2828
US

IV. Provider business mailing address

507 E 16TH ST STE 1
WELLINGTON KS
67152-2828
US

V. Phone/Fax

Practice location:
  • Phone: 620-326-3301
  • Fax: 620-326-7086
Mailing address:
  • Phone: 620-326-3301
  • Fax: 620-326-7086

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number15917
License Number StateKS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: