Healthcare Provider Details

I. General information

NPI: 1649214362
Provider Name (Legal Business Name): LARRY ALVIN WEITZENKAMP M. D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/15/2006
Last Update Date: 02/08/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

109 PUGH ST
MARTIN SD
57551-0370
US

IV. Provider business mailing address

PO BOX 370
MARTIN SD
57551-0370
US

V. Phone/Fax

Practice location:
  • Phone: 605-685-1450
  • Fax: 605-685-1453
Mailing address:
  • Phone: 605-685-1450
  • Fax: 605-685-1453

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number5461
License Number StateAK
# 2
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number2498
License Number StateSD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: