Provider Demographics
NPI:1174619068
Name:COLE, LARRY W (MD)
Entity type:Individual
Prefix:
First Name:LARRY
Middle Name:W
Last Name:COLE
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3245 INTERNATIONAL CIR
Mailing Address - Street 2:SUITE 200
Mailing Address - City:COLORADO SPRINGS
Mailing Address - State:CO
Mailing Address - Zip Code:80910-3152
Mailing Address - Country:US
Mailing Address - Phone:719-484-8840
Mailing Address - Fax:719-484-8845
Practice Address - Street 1:3245 INTERNATIONAL CIR
Practice Address - Street 2:SUITE 200
Practice Address - City:COLORADO SPRINGS
Practice Address - State:CO
Practice Address - Zip Code:80910-3152
Practice Address - Country:US
Practice Address - Phone:719-484-8840
Practice Address - Fax:719-484-8845
Is Sole Proprietor?:No
Enumeration Date:2006-10-05
Last Update Date:2009-05-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO17452207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO1174523Medicaid
COD23275Medicare UPIN
CO1174523Medicaid