Provider Demographics
NPI:1902194509
Name:ENBOM, ELENA
Entity Type:Individual
Prefix:
First Name:ELENA
Middle Name:
Last Name:ENBOM
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7300 MEDICAL CENTER DR
Mailing Address - Street 2:
Mailing Address - City:WEST HILLS
Mailing Address - State:CA
Mailing Address - Zip Code:91307-1902
Mailing Address - Country:US
Mailing Address - Phone:816-676-4124
Mailing Address - Fax:
Practice Address - Street 1:1000 W CARSON ST
Practice Address - Street 2:
Practice Address - City:TORRANCE
Practice Address - State:CA
Practice Address - Zip Code:90502-2004
Practice Address - Country:US
Practice Address - Phone:310-222-2911
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-07-16
Last Update Date:2017-05-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
CAA126989207ZP0102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207ZP0102XAllopathic & Osteopathic PhysiciansPathologyAnatomic Pathology & Clinical Pathology
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program