Provider Demographics
NPI:1174693659
Name:ENZENSPERGER, IRENE KAE (MD)
Entity type:Individual
Prefix:
First Name:IRENE
Middle Name:KAE
Last Name:ENZENSPERGER
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:IRENE
Other - Middle Name:KAE
Other - Last Name:SIRIKARANUN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:1060 E FOOTHILL BLVD STE 202
Mailing Address - Street 2:
Mailing Address - City:UPLAND
Mailing Address - State:CA
Mailing Address - Zip Code:91786-4017
Mailing Address - Country:US
Mailing Address - Phone:909-949-0220
Mailing Address - Fax:909-949-0309
Practice Address - Street 1:1060 E FOOTHILL BLVD STE 202
Practice Address - Street 2:
Practice Address - City:UPLAND
Practice Address - State:CA
Practice Address - Zip Code:91786-4017
Practice Address - Country:US
Practice Address - Phone:909-949-0220
Practice Address - Fax:909-949-0309
Is Sole Proprietor?:No
Enumeration Date:2006-11-09
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG23211207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00G232110Medicaid
CA00G232110Medicare ID - Type Unspecified
CA00G232110Medicaid