Healthcare Provider Details

I. General information

NPI: 1316923931
Provider Name (Legal Business Name): LARRY E. WARREN D.O.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/15/2005
Last Update Date: 08/26/2024
Certification Date: 08/26/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

130 KATE IRELAND DR
HYDEN KY
41749-9071
US

IV. Provider business mailing address

130 KATE IRELAND DR
HYDEN KY
41749-9071
US

V. Phone/Fax

Practice location:
  • Phone: 606-672-2341
  • Fax: 606-672-5254
Mailing address:
  • Phone: 606-672-2341
  • Fax: 606-672-5254

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number02875
License Number StateKY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: