Provider Demographics
NPI:1710366349
Name:LARSON, KATHLEEN (MD)
Entity type:Individual
Prefix:DR
First Name:KATHLEEN
Middle Name:
Last Name:LARSON
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4325 WILLIAMS BLVD SW
Mailing Address - Street 2:
Mailing Address - City:CEDAR RAPIDS
Mailing Address - State:IA
Mailing Address - Zip Code:52404-3436
Mailing Address - Country:US
Mailing Address - Phone:319-368-8400
Mailing Address - Fax:319-368-8405
Practice Address - Street 1:4325 WILLIAMS BLVD SW
Practice Address - Street 2:
Practice Address - City:CEDAR RAPIDS
Practice Address - State:IA
Practice Address - Zip Code:52404
Practice Address - Country:US
Practice Address - Phone:319-368-8400
Practice Address - Fax:319-368-8405
Is Sole Proprietor?:No
Enumeration Date:2015-05-28
Last Update Date:2018-07-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IAMD-45075208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
IAMD-45075OtherIOWA MEDICAL LICENSE