Provider Demographics
NPI:1073572434
Name:KESTIN, LARRY L
Entity Type:Individual
Prefix:
First Name:LARRY
Middle Name:L
Last Name:KESTIN
Suffix:
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 1:2234 COLONIAL BLVD
Mailing Address - Street 2:ATTN: PAYER CONTRACTING & RELATIONS
Mailing Address - City:FORT MYERS
Mailing Address - State:FL
Mailing Address - Zip Code:33907-1412
Mailing Address - Country:US
Mailing Address - Phone:239-931-7342
Mailing Address - Fax:239-931-7385
Practice Address - Street 1:70 FULTON ST
Practice Address - Street 2:
Practice Address - City:PONTIAC
Practice Address - State:MI
Practice Address - Zip Code:48341-2755
Practice Address - Country:US
Practice Address - Phone:248-338-0300
Practice Address - Fax:248-338-0663
Is Sole Proprietor?:No
Enumeration Date:2006-03-22
Last Update Date:2012-10-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI43010653772085R0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0001XAllopathic & Osteopathic PhysiciansRadiologyRadiation Oncology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI7283213OtherAETNA THRU OAKLAND PHYSICIANS NETWORK SERVICES
MI1046262OtherHEALTH PLUS OF MICHIGAN THRU OAKLAND PHYSICIANS NETWORK SERVICES (OPNS)
MI1073572434Medicaid
MI320F362430OtherBCBSM
MI7283213OtherAETNA
MI20974OtherHEALTH PLAN OF MICHIGAN
MI200812OtherUNITED HEALTHCARE COMMUNITY PLAN
MIP01013933OtherRAILROAD MEDICARE
MI1046262OtherHEALTH PLUS OF MICHIGAN THRU OAKLAND PHYSICIANS NETWORK SERVICES (OPNS)
MIH18077Medicare UPIN
MI1073572434Medicaid