Provider Demographics
NPI:1225010358
Name:KANJER-LARSON, LUCILLE E (MD)
Entity type:Individual
Prefix:DR
First Name:LUCILLE
Middle Name:E
Last Name:KANJER-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 1:205 N TILLOTSON AVE
Mailing Address - Street 2:
Mailing Address - City:MUNCIE
Mailing Address - State:IN
Mailing Address - Zip Code:47304-3900
Mailing Address - Country:US
Mailing Address - Phone:765-291-5437
Mailing Address - Fax:978-878-8498
Practice Address - Street 1:205 N TILLOTSON AVE
Practice Address - Street 2:
Practice Address - City:MUNCIE
Practice Address - State:IN
Practice Address - Zip Code:47304-3900
Practice Address - Country:US
Practice Address - Phone:765-291-5437
Practice Address - Fax:765-284-5387
Is Sole Proprietor?:No
Enumeration Date:2005-11-15
Last Update Date:2024-05-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01092632A208000000X
MA161078208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA3199738Medicaid
MAG98736Medicare UPIN
MAQX4182Medicare PIN