Basic Information
| Provider Information | |||||||||
| NPI: | 1760493779 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | DERKSEN | ||||||||
| FirstName: | LARRY | ||||||||
| MiddleName: | A | ||||||||
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| Credential: | D.O. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 8200 W CENTRAL AVE | ||||||||
| Address2: | SUITE 1 | ||||||||
| City: | WICHITA | ||||||||
| State: | KS | ||||||||
| PostalCode: | 672129503 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3167226260 | ||||||||
| FaxNumber: | 3167218307 | ||||||||
| Practice Location | |||||||||
| Address1: | 8200 W CENTRAL AVE | ||||||||
| Address2: | SUITE 1 | ||||||||
| City: | WICHITA | ||||||||
| State: | KS | ||||||||
| PostalCode: | 672129503 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3167226260 | ||||||||
| FaxNumber: | 3167218307 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/11/2006 | ||||||||
| LastUpdateDate: | 02/14/2011 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 523839 | KS | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 052013 | 01 | KS | BLUE CROSS BLUE SHIELD | OTHER | 4332116 | 01 | KS | AETNA | OTHER | 080110403 | 01 | KS | TRAVELERS MEDICARE | OTHER | 2863 | 01 | KS | PREFERRED HEALTH SYSTEMS | OTHER |