Provider Demographics
NPI:1134113822
Name:LARSON, RICHARD D (MD)
Entity Type:Individual
Prefix:
First Name:RICHARD
Middle Name:D
Last Name:LARSON
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2215 PORTLAND AVE
Mailing Address - Street 2:
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40212-1033
Mailing Address - Country:US
Mailing Address - Phone:502-774-8631
Mailing Address - Fax:
Practice Address - Street 1:2215 PORTLAND AVE
Practice Address - Street 2:
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40212-1033
Practice Address - Country:US
Practice Address - Phone:502-774-8631
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-09-08
Last Update Date:2011-03-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY27160207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY64271604Medicaid
KYP400036128Medicare PIN
KYP400036124Medicare PIN
B54460Medicare UPIN
KYP400036131Medicare PIN
KY0622301Medicare PIN
KY64271604Medicaid
KYP400036129Medicare PIN
KYP400036130Medicare PIN
KYP400036127Medicare PIN