Basic Information
| Provider Information | |||||||||
| NPI: | 1275507204 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | LARRINAGA | ||||||||
| FirstName: | JOHN | ||||||||
| MiddleName: | A | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 846098 | ||||||||
| Address2: | |||||||||
| City: | DALLAS | ||||||||
| State: | TX | ||||||||
| PostalCode: | 752846098 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9033246450 | ||||||||
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| Practice Location | |||||||||
| Address1: | 520 DOUGLAS BLVD | ||||||||
| Address2: | |||||||||
| City: | TYLER | ||||||||
| State: | TX | ||||||||
| PostalCode: | 757028307 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9035101175 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/15/2006 | ||||||||
| LastUpdateDate: | 10/13/2014 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2085R0202X | L4516 | TX | Y | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology |
ID Information
| ID | Type | State | Issuer | Description | 152466203 | 05 | TX | MEDICAID | 152466202 | 05 | TX | MEDICAID | 152450601 | 05 | TX | MEDICAID | 8CU211 | 01 | TX | BCBS MFH JV LOCATION | OTHER | 8B0526 | 01 | TX | BCBS | OTHER | 152466201 | 05 | TX | MEDICAID | TIN PLUS 005 | 01 | TX | TRICARE MFH JV LOCATION | OTHER | TIN PLUS 113 | 01 | TX | TRICARE | OTHER |