Provider Demographics
NPI:1689741795
Name:LARSON, KENNETH W (MD)
Entity Type:Individual
Prefix:DR
First Name:KENNETH
Middle Name:W
Last Name:LARSON
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 2580
Mailing Address - Street 2:
Mailing Address - City:SPRINGFIELD
Mailing Address - State:MO
Mailing Address - Zip Code:65801-2580
Mailing Address - Country:US
Mailing Address - Phone:417-829-4620
Mailing Address - Fax:
Practice Address - Street 1:1900 S NATIONAL AVE
Practice Address - Street 2:SUITE 1950
Practice Address - City:SPRINGFIELD
Practice Address - State:MO
Practice Address - Zip Code:65804-2265
Practice Address - Country:US
Practice Address - Phone:417-820-7250
Practice Address - Fax:417-820-7255
Is Sole Proprietor?:No
Enumeration Date:2006-11-30
Last Update Date:2013-05-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO105284208600000X, 2086S0127X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
No2086S0127XAllopathic & Osteopathic PhysiciansSurgeryTrauma Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO207672502Medicaid
MO431560263OtherTRICARE
MO207672502Medicaid
MOF83592Medicare UPIN