Provider Demographics
NPI:1013915859
Name:EENIGENBURG, LARA ANN (OD)
Entity Type:Individual
Prefix:DR
First Name:LARA
Middle Name:ANN
Last Name:EENIGENBURG
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:103 S DIVISION AVE
Mailing Address - Street 2:PO BOX E
Mailing Address - City:FREMONT
Mailing Address - State:MI
Mailing Address - Zip Code:49412-1602
Mailing Address - Country:US
Mailing Address - Phone:231-924-4110
Mailing Address - Fax:231-924-5007
Practice Address - Street 1:103 S DIVISION AVE
Practice Address - Street 2:PO BOX E
Practice Address - City:FREMONT
Practice Address - State:MI
Practice Address - Zip Code:49412-1602
Practice Address - Country:US
Practice Address - Phone:231-924-4110
Practice Address - Fax:231-924-5007
Is Sole Proprietor?:No
Enumeration Date:2005-07-13
Last Update Date:2008-05-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4901004195152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI4640938Medicaid
MI900F210120OtherBC BS OF MI
MI410014405OtherMEDICARE RAILROAD
MI4901004195OtherLICENSE NUMBER
MIN79710002Medicare ID - Type Unspecified
MI0220870001Medicare NSC
MIU97385Medicare UPIN