Healthcare Provider Details

I. General information

NPI: 1265480347
Provider Name (Legal Business Name): KIMBERLY DESTEFANO LARSEN MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/04/2006
Last Update Date: 05/21/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4225 ALTAMONT PL STE 201
WHITE PLAINS MD
20695-3065
US

IV. Provider business mailing address

9910 FRANKLIN SQUARE DR STE 2110
BALTIMORE MD
21236-4902
US

V. Phone/Fax

Practice location:
  • Phone: 240-607-1500
  • Fax:
Mailing address:
  • Phone: 410-933-5412
  • Fax: 410-535-6131

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberD51722
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: