Provider Demographics
NPI:1952462384
Name:LARSON, KENNETH G (OD)
Entity Type:Individual
Prefix:
First Name:KENNETH
Middle Name:G
Last Name:LARSON
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:540 1ST AVE
Mailing Address - Street 2:
Mailing Address - City:HALE
Mailing Address - State:MI
Mailing Address - Zip Code:48739-9158
Mailing Address - Country:US
Mailing Address - Phone:989-473-3459
Mailing Address - Fax:989-799-6500
Practice Address - Street 1:4580 STATE ST
Practice Address - Street 2:GREEN ACRES PLAZA
Practice Address - City:SAGINAW
Practice Address - State:MI
Practice Address - Zip Code:48603-3803
Practice Address - Country:US
Practice Address - Phone:989-799-0171
Practice Address - Fax:989-799-6500
Is Sole Proprietor?:No
Enumeration Date:2006-12-12
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4901002177152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist