Provider Demographics
NPI:1205695210
Name:LARGE, STANLEY III
Entity type:Individual
Prefix:MR
First Name:STANLEY
Middle Name:
Last Name:LARGE
Suffix:III
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1307 SW WASHINGTON AVE
Mailing Address - Street 2:
Mailing Address - City:LAWTON
Mailing Address - State:OK
Mailing Address - Zip Code:73501-7231
Mailing Address - Country:US
Mailing Address - Phone:580-355-7500
Mailing Address - Fax:
Practice Address - Street 1:1307 SW WASHINGTON AVE
Practice Address - Street 2:
Practice Address - City:LAWTON
Practice Address - State:OK
Practice Address - Zip Code:73501-7231
Practice Address - Country:US
Practice Address - Phone:580-355-7500
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-03-14
Last Update Date:2024-03-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes175T00000XOther Service ProvidersPeer Specialist