Provider Demographics
NPI:1568465300
Name:LARSEN, KEVIN J (DPM)
Entity Type:Individual
Prefix:
First Name:KEVIN
Middle Name:J
Last Name:LARSEN
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:PO BOX 5020
Mailing Address - Street 2:
Mailing Address - City:GRAND ISLAND
Mailing Address - State:NE
Mailing Address - Zip Code:68802-5020
Mailing Address - Country:US
Mailing Address - Phone:308-381-0404
Mailing Address - Fax:308-381-0408
Practice Address - Street 1:620 N DIERS AVE STE 100
Practice Address - Street 2:
Practice Address - City:GRAND ISLAND
Practice Address - State:NE
Practice Address - Zip Code:68803-4985
Practice Address - Country:US
Practice Address - Phone:308-381-0404
Practice Address - Fax:308-381-0408
Is Sole Proprietor?:No
Enumeration Date:2005-05-24
Last Update Date:2018-03-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE231213ES0103X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
NE280176OtherMEDICARE
NE02554OtherBLUE CROSS BLUE SHIELD
NE0152470001OtherDMERC CIGNA
NE470624979OtherCHAMPUS
NE480021904OtherRAILROAD MEDICARE
NE47062497913Medicaid
NE470624979OtherCHAMPUS