Provider Demographics
NPI:1447290622
Name:DEFFENBAUGH, LARRY D (DO)
Entity type:Individual
Prefix:DR
First Name:LARRY
Middle Name:D
Last Name:DEFFENBAUGH
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3114 MEDICAL PARK DR
Mailing Address - Street 2:
Mailing Address - City:CARTHAGE
Mailing Address - State:MO
Mailing Address - Zip Code:64836-1211
Mailing Address - Country:US
Mailing Address - Phone:620-783-2430
Mailing Address - Fax:
Practice Address - Street 1:3114 MEDICAL PARK DR
Practice Address - Street 2:
Practice Address - City:CARTHAGE
Practice Address - State:MO
Practice Address - Zip Code:64836-1211
Practice Address - Country:US
Practice Address - Phone:620-783-2430
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-06-07
Last Update Date:2021-10-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MOR6321207RG0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO826101068Medicare PIN