Provider Demographics
NPI:1164752358
Name:RABAA, LARA (MD)
Entity Type:Individual
Prefix:DR
First Name:LARA
Middle Name:
Last Name:RABAA
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:344 ARNOLD AVE
Mailing Address - Street 2:
Mailing Address - City:GREENVILLE
Mailing Address - State:MS
Mailing Address - Zip Code:38701-4711
Mailing Address - Country:US
Mailing Address - Phone:662-344-9100
Mailing Address - Fax:662-344-9120
Practice Address - Street 1:344 ARNOLD AVE
Practice Address - Street 2:
Practice Address - City:GREENVILLE
Practice Address - State:MS
Practice Address - Zip Code:38701-4711
Practice Address - Country:US
Practice Address - Phone:662-344-9100
Practice Address - Fax:662-344-9120
Is Sole Proprietor?:No
Enumeration Date:2010-01-11
Last Update Date:2013-03-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSMS22287208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS08174711Medicaid