Provider Demographics
NPI:1124393228
Name:RIES, LARA SPERANZA LAZARRE (MD)
Entity Type:Individual
Prefix:
First Name:LARA
Middle Name:SPERANZA LAZARRE
Last Name:RIES
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:LARA
Other - Middle Name:S
Other - Last Name:LAZARRE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 735044
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60673-5044
Mailing Address - Country:US
Mailing Address - Phone:920-802-2100
Mailing Address - Fax:
Practice Address - Street 1:3400 UNION AVE
Practice Address - Street 2:
Practice Address - City:SHEBOYGAN
Practice Address - State:WI
Practice Address - Zip Code:53081-8426
Practice Address - Country:US
Practice Address - Phone:920-802-2100
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-03-21
Last Update Date:2023-10-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IAR-96562084N0400X
HIMD-220412084N0400X
WI1007542084N0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurology
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI100246626Medicaid