Provider Demographics
NPI:1780682955
Name:MEHRENS, HENNING (MD)
Entity Type:Individual
Prefix:DR
First Name:HENNING
Middle Name:
Last Name:MEHRENS
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 1:1111 EMERALD BAY RD
Mailing Address - Street 2:
Mailing Address - City:SOUTH LAKE TAHOE
Mailing Address - State:CA
Mailing Address - Zip Code:96150-6207
Mailing Address - Country:US
Mailing Address - Phone:530-543-5659
Mailing Address - Fax:530-541-8723
Practice Address - Street 1:2130 LAKE TAHOE BLVD
Practice Address - Street 2:
Practice Address - City:SOUTH LAKE TAHOE
Practice Address - State:CA
Practice Address - Zip Code:96150-6405
Practice Address - Country:US
Practice Address - Phone:530-541-3277
Practice Address - Fax:530-541-6913
Is Sole Proprietor?:No
Enumeration Date:2005-07-12
Last Update Date:2014-07-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAC32445207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CABW921ZMedicare PIN
CA1780682955Medicaid
A34940Medicare UPIN
CABW921YMedicare PIN