Provider Demographics
NPI:1437195609
Name:TATUM, LARRY D (MD)
Entity type:Individual
Prefix:
First Name:LARRY
Middle Name:D
Last Name:TATUM
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:PO BOX 961205
Mailing Address - Street 2:
Mailing Address - City:FORT WORTH
Mailing Address - State:TX
Mailing Address - Zip Code:76161-1205
Mailing Address - Country:US
Mailing Address - Phone:817-740-8400
Mailing Address - Fax:817-921-2701
Practice Address - Street 1:1250 8TH AVE STE 430
Practice Address - Street 2:
Practice Address - City:FORT WORTH
Practice Address - State:TX
Practice Address - Zip Code:76104-4144
Practice Address - Country:US
Practice Address - Phone:817-923-5558
Practice Address - Fax:817-923-0087
Is Sole Proprietor?:No
Enumeration Date:2006-06-22
Last Update Date:2020-02-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXF4585207VG0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207VG0400XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX047134403Medicaid
TX047134405Medicaid
160059746OtherRAILROAD
160059746OtherRAILROAD
TX8G3643Medicare PIN
TX047134403Medicaid