Healthcare Provider Details

I. General information

NPI: 1851486575
Provider Name (Legal Business Name): LARKIN TYLER WADSWORTH III MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/04/2006
Last Update Date: 08/10/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8225 CLAYTON RD
SAINT LOUIS MO
63117-1107
US

IV. Provider business mailing address

8225 CLAYTON RD
SAINT LOUIS MO
63117-1107
US

V. Phone/Fax

Practice location:
  • Phone: 314-721-7325
  • Fax: 314-721-1157
Mailing address:
  • Phone: 314-721-7325
  • Fax: 314-721-1157

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207QS0010X
TaxonomySports Medicine (Family Medicine) Physician
License Number103386
License Number StateMO
# 2
Primary TaxonomyN
Taxonomy Code207QS0010X
TaxonomySports Medicine (Family Medicine) Physician
License Number036118172
License Number StateIL
# 3
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number036118172
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: