Provider Demographics
NPI:1356319107
Name:LARES, TODD A (MD)
Entity Type:Individual
Prefix:
First Name:TODD
Middle Name:A
Last Name:LARES
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:809 MINERAL RD
Mailing Address - Street 2:
Mailing Address - City:GLENVILLE
Mailing Address - State:WV
Mailing Address - Zip Code:26351-1385
Mailing Address - Country:US
Mailing Address - Phone:304-462-7322
Mailing Address - Fax:304-462-4052
Practice Address - Street 1:809 MINERAL RD
Practice Address - Street 2:
Practice Address - City:GLENVILLE
Practice Address - State:WV
Practice Address - Zip Code:26351-1385
Practice Address - Country:US
Practice Address - Phone:304-462-7322
Practice Address - Fax:304-462-4052
Is Sole Proprietor?:No
Enumeration Date:2006-03-09
Last Update Date:2008-12-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV19106207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
G77238Medicare UPIN