Provider Demographics
NPI:1003226226
Name:EISA, LARA (MD)
Entity Type:Individual
Prefix:
First Name:LARA
Middle Name:
Last Name:EISA
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:LARA
Other - Middle Name:
Other - Last Name:ABDEL-SHAFEI EISA
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:25 MORRISSEY BLVD UNIT 1130
Mailing Address - Street 2:
Mailing Address - City:DORCHESTER
Mailing Address - State:MA
Mailing Address - Zip Code:02125-3354
Mailing Address - Country:US
Mailing Address - Phone:716-364-8535
Mailing Address - Fax:
Practice Address - Street 1:3435 MAIN ST
Practice Address - Street 2:252 FARBER HALL
Practice Address - City:BUFFALO
Practice Address - State:NY
Practice Address - Zip Code:14214-3001
Practice Address - Country:US
Practice Address - Phone:716-829-6102
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-04-28
Last Update Date:2019-08-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
MA273761207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program