Provider Demographics
NPI:1659451441
Name:LARSON, KENNETH ANDREW (M D)
Entity Type:Individual
Prefix:
First Name:KENNETH
Middle Name:ANDREW
Last Name:LARSON
Suffix:
Gender:M
Credentials:M D
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5511 S CONGRESS AVE
Mailing Address - Street 2:SUITE 105
Mailing Address - City:ATLANTIS
Mailing Address - State:FL
Mailing Address - Zip Code:33462-1140
Mailing Address - Country:US
Mailing Address - Phone:561-964-1635
Mailing Address - Fax:561-964-1636
Practice Address - Street 1:5511 S CONGRESS AVE
Practice Address - Street 2:SUITE 105
Practice Address - City:ATLANTIS
Practice Address - State:FL
Practice Address - Zip Code:33462-1140
Practice Address - Country:US
Practice Address - Phone:561-964-1635
Practice Address - Fax:561-964-1636
Is Sole Proprietor?:No
Enumeration Date:2006-10-16
Last Update Date:2022-02-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME088693208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL270211800Medicaid
FL270211800Medicaid
FLI06054Medicare UPIN