Provider Demographics
NPI:1043352214
Name:ENEBOE, PAUL LEO (MD)
Entity Type:Individual
Prefix:
First Name:PAUL
Middle Name:LEO
Last Name:ENEBOE
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4136 BARTLETT ST
Mailing Address - Street 2:HOMER MEDICAL CLINIC
Mailing Address - City:HOMER
Mailing Address - State:AK
Mailing Address - Zip Code:99603-7015
Mailing Address - Country:US
Mailing Address - Phone:907-235-8586
Mailing Address - Fax:907-235-6639
Practice Address - Street 1:4136 BARTLETT ST
Practice Address - Street 2:HOMER MEDICAL CLINIC
Practice Address - City:HOMER
Practice Address - State:AK
Practice Address - Zip Code:99603-7015
Practice Address - Country:US
Practice Address - Phone:907-235-8586
Practice Address - Fax:907-235-6639
Is Sole Proprietor?:No
Enumeration Date:2007-02-13
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AK583207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
AKMD0583Medicaid
AKMD0583Medicaid
AKK038WCJGWAMedicare ID - Type Unspecified
AE1128784OtherDEA