Provider Demographics
NPI:1114064920
Name:LARA, ABEL JR
Entity Type:Individual
Prefix:MR
First Name:ABEL
Middle Name:
Last Name:LARA
Suffix:JR
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2710 N HARBOR DR
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92101-1028
Mailing Address - Country:US
Mailing Address - Phone:619-278-7130
Mailing Address - Fax:619-278-7132
Practice Address - Street 1:2710 N HARBOR DR
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92101-1028
Practice Address - Country:US
Practice Address - Phone:619-278-7130
Practice Address - Fax:619-278-7132
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-31
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAB1581660146N00000X
1710I1002X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered146N00000XEmergency Medical Service ProvidersEmergency Medical Technician, Basic
Not Answered1710I1002XOther Service ProvidersMilitary Health Care ProviderIndependent Duty Corpsman