Healthcare Provider Details

I. General information

NPI: 1437356235
Provider Name (Legal Business Name): LARS PETER ENEVOLDSEN M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/27/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

220 W ORANGEBURG AVE
MODESTO CA
95350-4417
US

IV. Provider business mailing address

220 W ORANGEBURG AVE
MODESTO CA
95350-4417
US

V. Phone/Fax

Practice location:
  • Phone: 209-524-6204
  • Fax: 209-524-0405
Mailing address:
  • Phone: 209-524-6204
  • Fax: 209-524-0405

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208200000X
TaxonomyPlastic Surgery Physician
License NumberG56199
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: