Provider Demographics
NPI:1033177829
Name:THEAD, LARRY B (MD)
Entity type:Individual
Prefix:DR
First Name:LARRY
Middle Name:B
Last Name:THEAD
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 1:1700 SPRING HILL AVE STE 100
Mailing Address - Street 2:
Mailing Address - City:MOBILE
Mailing Address - State:AL
Mailing Address - Zip Code:36604-1416
Mailing Address - Country:US
Mailing Address - Phone:251-435-1200
Mailing Address - Fax:
Practice Address - Street 1:95 SHELL RD
Practice Address - Street 2:
Practice Address - City:SARALAND
Practice Address - State:AL
Practice Address - Zip Code:36571-2202
Practice Address - Country:US
Practice Address - Phone:251-675-4733
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-05-02
Last Update Date:2021-02-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL9264207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
ALC70461Medicare UPIN
51523156Medicare ID - Type Unspecified