Provider Demographics
NPI:1235161597
Name:HUSTANA, LARA DAWN (OD)
Entity Type:Individual
Prefix:DR
First Name:LARA
Middle Name:DAWN
Last Name:HUSTANA
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:FILE 57326
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90074-0001
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:9415 CAMPUS POINT DR
Practice Address - Street 2:
Practice Address - City:LA JOLLA
Practice Address - State:CA
Practice Address - Zip Code:92037-1350
Practice Address - Country:US
Practice Address - Phone:858-534-6291
Practice Address - Fax:858-822-4438
Is Sole Proprietor?:No
Enumeration Date:2006-07-07
Last Update Date:2024-01-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAOPT11472T152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CASDO114720Medicaid
CAWO911472AMedicare ID - Type Unspecified
CASDO114720Medicaid