Basic Information
| Provider Information | |||||||||
| NPI: | 1265480347 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | LARSEN | ||||||||
| FirstName: | KIMBERLY | ||||||||
| MiddleName: | DESTEFANO | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 9910 FRANKLIN SQUARE DR STE 2110 | ||||||||
| Address2: | |||||||||
| City: | BALTIMORE | ||||||||
| State: | MD | ||||||||
| PostalCode: | 212364902 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4109335412 | ||||||||
| FaxNumber: | 4105356131 | ||||||||
| Practice Location | |||||||||
| Address1: | 4225 ALTAMONT PL STE 201 | ||||||||
| Address2: | |||||||||
| City: | WHITE PLAINS | ||||||||
| State: | MD | ||||||||
| PostalCode: | 206953065 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2406071500 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 05/04/2006 | ||||||||
| LastUpdateDate: | 05/21/2018 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | D51722 | MD | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 5619003 | 01 | BCBS FEDERAL | OTHER | 123200560 | 05 | MD | MEDICAID |