Provider Demographics
NPI:1265480347
Name:LARSEN, KIMBERLY DESTEFANO (MD)
Entity Type:Individual
Prefix:DR
First Name:KIMBERLY
Middle Name:DESTEFANO
Last Name:LARSEN
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9910 FRANKLIN SQUARE DR STE 2110
Mailing Address - Street 2:
Mailing Address - City:BALTIMORE
Mailing Address - State:MD
Mailing Address - Zip Code:21236-4902
Mailing Address - Country:US
Mailing Address - Phone:410-933-5412
Mailing Address - Fax:410-535-6131
Practice Address - Street 1:4225 ALTAMONT PL STE 201
Practice Address - Street 2:
Practice Address - City:WHITE PLAINS
Practice Address - State:MD
Practice Address - Zip Code:20695-3065
Practice Address - Country:US
Practice Address - Phone:240-607-1500
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-05-04
Last Update Date:2018-05-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDD51722207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
5619003OtherBCBS FEDERAL
MD123200560Medicaid
G58635Medicare UPIN
517LMedicare ID - Type UnspecifiedPRACTICE