Healthcare Provider Details

I. General information

NPI: 1659638062
Provider Name (Legal Business Name): LARS MIKAEL STENSMAN M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/23/2012
Last Update Date: 05/16/2022
Certification Date: 05/16/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1620 ALPINE BLVD STE 116
ALPINE CA
91901-1103
US

IV. Provider business mailing address

1620 ALPINE BLVD STE 116
ALPINE CA
91901-1103
US

V. Phone/Fax

Practice location:
  • Phone: 619-662-4100
  • Fax:
Mailing address:
  • Phone: 619-662-4100
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberMED-PHYS-LIC-41023
License Number StateMT
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number0116024330
License Number StateVA
# 3
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberA158569
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: