Provider Demographics
NPI:1073501235
Name:PESAVENTO, LARA JANE
Entity Type:Individual
Prefix:
First Name:LARA
Middle Name:JANE
Last Name:PESAVENTO
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:PO BOX 7232
Mailing Address - Street 2:DEPT 118
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46207-7232
Mailing Address - Country:US
Mailing Address - Phone:317-567-2180
Mailing Address - Fax:317-614-9655
Practice Address - Street 1:1701 N SENATE BLVD
Practice Address - Street 2:
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46202-1239
Practice Address - Country:US
Practice Address - Phone:317-567-2180
Practice Address - Fax:317-614-9655
Is Sole Proprietor?:No
Enumeration Date:2005-10-12
Last Update Date:2021-07-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01061430207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200849010Medicaid
DC017073M65Medicare PIN
IN200849010Medicaid
IN170580DDDDMedicare PIN