Provider Demographics
NPI:1346508280
Name:GLESNE, KURT LARSON (DPM)
Entity Type:Individual
Prefix:DR
First Name:KURT
Middle Name:LARSON
Last Name:GLESNE
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
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Mailing Address - Street 1:2351 BROADWAY ST
Mailing Address - Street 2:
Mailing Address - City:PEKIN
Mailing Address - State:IL
Mailing Address - Zip Code:61554-3972
Mailing Address - Country:US
Mailing Address - Phone:309-353-4159
Mailing Address - Fax:309-353-4531
Practice Address - Street 1:2351 BROADWAY ST
Practice Address - Street 2:
Practice Address - City:PEKIN
Practice Address - State:IL
Practice Address - Zip Code:61554-3972
Practice Address - Country:US
Practice Address - Phone:309-353-4159
Practice Address - Fax:309-353-4531
Is Sole Proprietor?:No
Enumeration Date:2012-04-29
Last Update Date:2013-12-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPO 3503213ES0103X
IL016.005522213ES0103X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle Surgery