Provider Demographics
NPI:1083907471
Name:KETCHERSIDE, LARRY K (DPM)
Entity Type:Individual
Prefix:DR
First Name:LARRY
Middle Name:K
Last Name:KETCHERSIDE
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9110 LEESGATE RD
Mailing Address - Street 2:
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40222-5053
Mailing Address - Country:US
Mailing Address - Phone:502-426-7222
Mailing Address - Fax:502-425-8226
Practice Address - Street 1:9110 LEESGATE RD
Practice Address - Street 2:
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40222-5053
Practice Address - Country:US
Practice Address - Phone:502-426-7222
Practice Address - Fax:502-425-8226
Is Sole Proprietor?:No
Enumeration Date:2011-05-18
Last Update Date:2014-01-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY00358213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY7100165100Medicaid
KYK005870Medicare PIN