Provider Demographics
NPI:1598792509
Name:LARSON, EARL KENNETH JR (MD)
Entity Type:Individual
Prefix:DR
First Name:EARL
Middle Name:KENNETH
Last Name:LARSON
Suffix:JR
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:123 W 31ST ST
Mailing Address - Street 2:
Mailing Address - City:KEARNEY
Mailing Address - State:NE
Mailing Address - Zip Code:68847-2916
Mailing Address - Country:US
Mailing Address - Phone:308-237-7719
Mailing Address - Fax:308-236-6975
Practice Address - Street 1:123 W 31ST ST
Practice Address - Street 2:
Practice Address - City:KEARNEY
Practice Address - State:NE
Practice Address - Zip Code:68847-2916
Practice Address - Country:US
Practice Address - Phone:308-237-7719
Practice Address - Fax:308-236-6975
Is Sole Proprietor?:No
Enumeration Date:2006-06-26
Last Update Date:2013-02-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE11217208800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208800000XAllopathic & Osteopathic PhysiciansUrology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NE47057331013Medicaid
NED05087Medicare UPIN
NE47057331013Medicaid