Healthcare Provider Details

I. General information

NPI: 1518903160
Provider Name (Legal Business Name): LARRY KYLE HRDLICKA D.O.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/21/2006
Last Update Date: 12/21/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1220 N FLORENCE AVE
CLAREMORE OK
74017-4381
US

IV. Provider business mailing address

1220 N FLORENCE AVE
CLAREMORE OK
74017-4381
US

V. Phone/Fax

Practice location:
  • Phone: 918-341-5311
  • Fax: 918-341-7338
Mailing address:
  • Phone: 918-341-5311
  • Fax: 918-341-7338

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208600000X
TaxonomySurgery Physician
License Number8161
License Number StateOK

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: