Provider Demographics
NPI:1447397708
Name:WIDDEL, LARS (MD)
Entity Type:Individual
Prefix:DR
First Name:LARS
Middle Name:
Last Name:WIDDEL
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 1:3400 DATA DR
Mailing Address - Street 2:
Mailing Address - City:RANCHO CORDOVA
Mailing Address - State:CA
Mailing Address - Zip Code:95670-7956
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2624 EDITH AVE
Practice Address - Street 2:
Practice Address - City:REDDING
Practice Address - State:CA
Practice Address - Zip Code:96001-3043
Practice Address - Country:US
Practice Address - Phone:530-806-1190
Practice Address - Fax:530-229-7946
Is Sole Proprietor?:No
Enumeration Date:2007-01-30
Last Update Date:2021-06-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAC171096207T00000X
CO46386207T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207T00000XAllopathic & Osteopathic PhysiciansNeurological Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
WY133174400Medicaid
CO28680821Medicaid
COP01159599OtherMEDICARE RAILROAD
WY133174400Medicaid