Healthcare Provider Details

I. General information

NPI: 1093808545
Provider Name (Legal Business Name): LARS E. VANDERBUR M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/02/2006
Last Update Date: 04/03/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9202 WEST DODGE ROAD SUITE 101
OMAHA NE
68114
US

IV. Provider business mailing address

8401 WEST DODGE ROAD SUITE 280
OMAHA NE
68114
US

V. Phone/Fax

Practice location:
  • Phone: 402-955-7500
  • Fax: 402-955-7524
Mailing address:
  • Phone: 402-955-6877
  • Fax: 402-955-6880

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number22271
License Number StateNE

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: