Provider Demographics
NPI:1659633709
Name:MITNAUL, LARRY DAVID JR (MD, MPH, MS)
Entity Type:Individual
Prefix:DR
First Name:LARRY
Middle Name:DAVID
Last Name:MITNAUL
Suffix:JR
Gender:M
Credentials:MD, MPH, MS
Other - Prefix:
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Mailing Address - Street 1:1515 S CLIFTON AVE STE 300
Mailing Address - Street 2:
Mailing Address - City:WICHITA
Mailing Address - State:KS
Mailing Address - Zip Code:67218-2953
Mailing Address - Country:US
Mailing Address - Phone:316-858-0550
Mailing Address - Fax:316-858-0596
Practice Address - Street 1:1515 S CLIFTON AVE STE 300
Practice Address - Street 2:
Practice Address - City:WICHITA
Practice Address - State:KS
Practice Address - Zip Code:67218-2953
Practice Address - Country:US
Practice Address - Phone:316-858-0550
Practice Address - Fax:316-858-0596
Is Sole Proprietor?:No
Enumeration Date:2012-06-14
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
390200000X
KS04-401942084P0804X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0804XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyChild & Adolescent Psychiatry
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program