Basic Information
| Provider Information | |||||||||
| NPI: | 1407970700 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | LARUE | ||||||||
| FirstName: | DAVID | ||||||||
| MiddleName: | MALCOLM | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | D.O. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 11426 GOLDENROD RD | ||||||||
| Address2: | |||||||||
| City: | CARTHAGE | ||||||||
| State: | MO | ||||||||
| PostalCode: | 648364176 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4173582529 | ||||||||
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| Practice Location | |||||||||
| Address1: | 210 NE TUDOR | ||||||||
| Address2: | |||||||||
| City: | LEES SUMMITT | ||||||||
| State: | MO | ||||||||
| PostalCode: | 640865696 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8882563814 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 03/19/2007 | ||||||||
| LastUpdateDate: | 01/31/2017 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207P00000X | R9J48 | MO | N | Allopathic & Osteopathic Physicians | Emergency Medicine | 261QH0100X | R9J48 | MO | Y | Ambulatory Health Care Facilities | Clinic/Center | Health Service |
ID Information
| ID | Type | State | Issuer | Description | 242956100 | 05 | MO | MEDICAID |