Provider Demographics
NPI:1659325454
Name:FREISBERG, LARS (MD)
Entity Type:Individual
Prefix:
First Name:LARS
Middle Name:
Last Name:FREISBERG
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 1:9343 S MINGO RD
Mailing Address - Street 2:
Mailing Address - City:TULSA
Mailing Address - State:OK
Mailing Address - Zip Code:74133-5702
Mailing Address - Country:US
Mailing Address - Phone:918-949-4577
Mailing Address - Fax:918-743-8624
Practice Address - Street 1:9343 S MINGO RD
Practice Address - Street 2:
Practice Address - City:TULSA
Practice Address - State:OK
Practice Address - Zip Code:74133-5702
Practice Address - Country:US
Practice Address - Phone:918-949-4577
Practice Address - Fax:918-743-8624
Is Sole Proprietor?:No
Enumeration Date:2006-05-19
Last Update Date:2015-10-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK26611207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI5215160Medicaid
MIP00458701OtherMEDICARE RR
MIP00458701OtherMEDICARE RR
OKOK401097Medicare PIN
MI0364980001Medicare NSC
MI0D17001Medicare PIN