Healthcare Provider Details

I. General information

NPI: 1750389862
Provider Name (Legal Business Name): LARS DOUGLAS ENSIGN MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/12/2005
Last Update Date: 03/17/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2170 SOUTH AVE
SOUTH LAKE TAHOE CA
96150-7026
US

IV. Provider business mailing address

1111 EMERALD BAY RD
SOUTH LAKE TAHOE CA
96150-6207
US

V. Phone/Fax

Practice location:
  • Phone: 530-541-3420
  • Fax:
Mailing address:
  • Phone: 530-543-5639
  • Fax: 530-541-8723

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License Number9855
License Number StateNV
# 2
Primary TaxonomyY
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License NumberA75593
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: