Provider Demographics
NPI:1760493779
Name:DERKSEN, LARRY A (DO)
Entity type:Individual
Prefix:
First Name:LARRY
Middle Name:A
Last Name:DERKSEN
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8200 W CENTRAL AVE
Mailing Address - Street 2:SUITE 1
Mailing Address - City:WICHITA
Mailing Address - State:KS
Mailing Address - Zip Code:67212-9503
Mailing Address - Country:US
Mailing Address - Phone:316-722-6260
Mailing Address - Fax:316-721-8307
Practice Address - Street 1:8200 W CENTRAL AVE
Practice Address - Street 2:SUITE 1
Practice Address - City:WICHITA
Practice Address - State:KS
Practice Address - Zip Code:67212-9503
Practice Address - Country:US
Practice Address - Phone:316-722-6260
Practice Address - Fax:316-721-8307
Is Sole Proprietor?:No
Enumeration Date:2006-08-11
Last Update Date:2011-02-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS523839207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
KS052013OtherBLUE CROSS BLUE SHIELD
KS4332116OtherAETNA
KS080110403OtherTRAVELERS MEDICARE
KS2863OtherPREFERRED HEALTH SYSTEMS
KS052013Medicare ID - Type Unspecified
KS2863OtherPREFERRED HEALTH SYSTEMS