Healthcare Provider Details

I. General information

NPI: 1992754345
Provider Name (Legal Business Name): LARRY RALPH FANE M. D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/10/2006
Last Update Date: 03/09/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

612 E UNIVERSITY AVE
GEORGETOWN TX
78626-7034
US

IV. Provider business mailing address

205 E UNIVERSITY AVE SUITE 200
GEORGETOWN TX
78626-6814
US

V. Phone/Fax

Practice location:
  • Phone: 512-930-5437
  • Fax:
Mailing address:
  • Phone: 512-686-0207
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberD7566
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: