Provider Demographics
NPI:1952406027
Name:LARSEN, KENNETH THEODORE JR (MD)
Entity type:Individual
Prefix:
First Name:KENNETH
Middle Name:THEODORE
Last Name:LARSEN
Suffix:JR
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 1:10599 WARLAND RD
Mailing Address - Street 2:
Mailing Address - City:MARSHALL
Mailing Address - State:VA
Mailing Address - Zip Code:20115-2365
Mailing Address - Country:US
Mailing Address - Phone:540-364-2885
Mailing Address - Fax:540-364-9472
Practice Address - Street 1:500 HOSPITAL DR
Practice Address - Street 2:
Practice Address - City:WARRENTON
Practice Address - State:VA
Practice Address - Zip Code:20186-3027
Practice Address - Country:US
Practice Address - Phone:540-347-4078
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-14
Last Update Date:2025-05-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101021589207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA930106972Medicare PIN
VA930002019Medicare PIN