Provider Demographics
NPI:1124178009
Name:LARSON, STUART (MD)
Entity type:Individual
Prefix:
First Name:STUART
Middle Name:
Last Name:LARSON
Suffix:
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:PO BOX 990
Mailing Address - Street 2:
Mailing Address - City:DANVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40423-0990
Mailing Address - Country:US
Mailing Address - Phone:859-239-2360
Mailing Address - Fax:859-239-5579
Practice Address - Street 1:120 DANIEL DR
Practice Address - Street 2:
Practice Address - City:DANVILLE
Practice Address - State:KY
Practice Address - Zip Code:40422-2527
Practice Address - Country:US
Practice Address - Phone:859-239-5570
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-01-11
Last Update Date:2023-02-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY276522084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY30615058Medicaid
KY30604011Medicaid
KYK0184401OtherMEDICARE PTAN
KYF15678Medicare UPIN
KY0045388Medicare ID - Type UnspecifiedMEDICARE
KY0331002Medicare ID - Type UnspecifiedMEDICARE
KY0045465Medicare ID - Type UnspecifiedMEDICARE
KY0454Medicare ID - Type UnspecifiedMEDICARE
KY30604011Medicaid