Provider Demographics
NPI:1447455662
Name:LARISON, HEIDI D (DO)
Entity type:Individual
Prefix:
First Name:HEIDI
Middle Name:D
Last Name:LARISON
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:HEIDI
Other - Middle Name:
Other - Last Name:LAFORGE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:DO
Mailing Address - Street 1:2230 N RIDGE RD
Mailing Address - Street 2:
Mailing Address - City:WICHITA
Mailing Address - State:KS
Mailing Address - Zip Code:67205-1053
Mailing Address - Country:US
Mailing Address - Phone:316-448-8339
Mailing Address - Fax:
Practice Address - Street 1:2230 N RIDGE RD
Practice Address - Street 2:
Practice Address - City:WICHITA
Practice Address - State:KS
Practice Address - Zip Code:67205-1053
Practice Address - Country:US
Practice Address - Phone:316-448-8339
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-06-18
Last Update Date:2021-01-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS05-33442207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
003719184OtherMEDICARE
KS200658020BMedicaid
KS200658020BMedicaid