Provider Demographics
NPI:1073699559
Name:LARE, SANDRA (DO)
Entity Type:Individual
Prefix:DR
First Name:SANDRA
Middle Name:
Last Name:LARE
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:702 SUNSET DR
Mailing Address - Street 2:
Mailing Address - City:ONTARIO
Mailing Address - State:OR
Mailing Address - Zip Code:97914-3121
Mailing Address - Country:US
Mailing Address - Phone:541-889-9167
Mailing Address - Fax:
Practice Address - Street 1:2609 S 10TH AVE STE 102
Practice Address - Street 2:
Practice Address - City:CALDWELL
Practice Address - State:ID
Practice Address - Zip Code:83605-6885
Practice Address - Country:US
Practice Address - Phone:208-454-2766
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-27
Last Update Date:2021-02-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA20A78362084P0800X
SC04792084P0800X
NC2005-015642084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
H53930Medicare UPIN