Provider Demographics
NPI:1568482453
Name:MCDONALD, LARRY VAIL (MD)
Entity Type:Individual
Prefix:
First Name:LARRY
Middle Name:VAIL
Last Name:MCDONALD
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:PO BOX 8580
Mailing Address - Street 2:
Mailing Address - City:PRAIRIE VILLAGE
Mailing Address - State:KS
Mailing Address - Zip Code:66208-0580
Mailing Address - Country:US
Mailing Address - Phone:913-901-8223
Mailing Address - Fax:913-901-0093
Practice Address - Street 1:3100 NE 83RD ST
Practice Address - Street 2:SUITE 1001
Practice Address - City:KANSAS CITY
Practice Address - State:MO
Practice Address - Zip Code:64119-4400
Practice Address - Country:US
Practice Address - Phone:816-468-0400
Practice Address - Fax:816-468-6623
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-20
Last Update Date:2014-06-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS04-164102084P0804X
MOR6F272084P0804X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0804XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyChild & Adolescent Psychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
KS100152920CMedicaid
MO1568482453Medicaid
KS100152920CMedicaid
MO1568482453Medicaid