Provider Demographics
NPI:1639138431
Name:LARSON, KEITH D (MD)
Entity type:Individual
Prefix:
First Name:KEITH
Middle Name:D
Last Name:LARSON
Suffix:
Gender:M
Credentials:MD
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Other - First Name:
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Other - Last Name:
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Mailing Address - Street 1:1511 NORTHWAY DR
Mailing Address - Street 2:SUITE 202
Mailing Address - City:SAINT CLOUD
Mailing Address - State:MN
Mailing Address - Zip Code:56303-1261
Mailing Address - Country:US
Mailing Address - Phone:320-217-8880
Mailing Address - Fax:320-253-1822
Practice Address - Street 1:1511 NORTHWAY DR
Practice Address - Street 2:SUITE 202
Practice Address - City:SAINT CLOUD
Practice Address - State:MN
Practice Address - Zip Code:56303-1261
Practice Address - Country:US
Practice Address - Phone:320-217-8880
Practice Address - Fax:320-253-1822
Is Sole Proprietor?:Yes
Enumeration Date:2006-03-21
Last Update Date:2009-09-01
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MN226932084N0402X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084N0402XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurology with Special Qualifications in Child Neurology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN313593400Medicaid
130000657Medicare ID - Type Unspecified
MN313593400Medicaid