Provider Demographics
NPI:1134649007
Name:KOSE, LARA (MD)
Entity Type:Individual
Prefix:MS
First Name:LARA
Middle Name:
Last Name:KOSE
Suffix:
Gender:F
Credentials:MD
Other - Prefix:MRS
Other - First Name:LARA
Other - Middle Name:
Other - Last Name:DEFTERDERIAN
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MD
Mailing Address - Street 1:15503 VENTURA BLVD STE 350
Mailing Address - Street 2:
Mailing Address - City:ENCINO
Mailing Address - State:CA
Mailing Address - Zip Code:91436-3114
Mailing Address - Country:US
Mailing Address - Phone:818-461-8148
Mailing Address - Fax:
Practice Address - Street 1:15503 VENTURA BLVD STE 350
Practice Address - Street 2:
Practice Address - City:ENCINO
Practice Address - State:CA
Practice Address - Zip Code:91436-3114
Practice Address - Country:US
Practice Address - Phone:818-461-8148
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-06-22
Last Update Date:2020-06-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA157259207R00000X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program